The Effectiveness of Low Vision Rehabilitation on Occupational Performance and Quality of Life among Older Adults with Low Vision

Faculty Investigators: Shirley J. Jackson, MS, OTR/L, FAOTA & Anne L. Morris, Ed.D.,OTR/L, SCEM, FAOTA,

CAPS

Student Investigators : Sonya Finklin, MSOT Candidate & Christina Popoola, MSOT Candidate

Purpose•The purpose of this study was to investigate

the effectiveness of occupational therapy low vision rehabilitation for older adults with low vision.

•The objective of this research was to determine if the participant’s occupational performance and quality of life has been enhanced or weakened following low vision rehabilitation.

Background• In the United States, vision impairment affects

approximately 21% of adults 65 years of age and older (7.3 million persons), including low vision, (Lighthouse International, 2001).

•The aging population in the U.S. and documented annual rise in low vision incidence indicates that the number of older adults with low vision impairments will continue to increase over the next half century (Leat, Fryer, & Rumney, 2004).

Significance • In this study a vision-specific quality of life

assessment was used in a clinical setting to evaluate low-vision rehabilitation strategies and management. Original research involved one hundred fifty patients with low vision who completed the low-vision questionnaire before and after their rehabilitation.

•Those results showed that the assessment quantified the quality of life of those clients with low vision indicating an improvement in the patients after receiving low-vision rehabilitation (Wolffsohn, 2000).

Significance(continued)•Girdler et al (2008) conducted a study that

examined the impact of age-related vision loss, identified the factors that influence adaptation, and described the perceived problem areas in the daily lives of older adults.

•Findings showed that the importance of occupation is adaptation to vision loss; and how their vision loss was perceived that served as a significant marker and pivotal point in their lives.

Significance(continued)

Conversely, others have reported that extended education in the use of low vision aids resulted in significantly improved ability to read, increased perception of quality of life, higher satisfaction with service, and more frequent use of low vision aids (Shuttleworth, Dunlop, Collins, & James, 1995).

Operational Definitions

•Occupational Performance is operationally defined as improved activity potential in areas of distance vision, mobility, level of lighting for use in reading and fine work, and activities of daily living.

•Quality of Life is defined as the satisfaction achieved from exploring yourself, living to your potential and finding balance in your everyday life through personal and professional activities.

Operational Definition(cont.)

• Low Vision is a level of visual impairment where functional limitations of the eye(s) manifest as reduced visual acuity or contrast sensitivity, visual field loss, visual distortion, or altered visual perception.

• It is defined as permanent visual impairment that is not correctable with spectacles, contact lenses, or surgical intervention and interferes with normal everyday activities.

Research Question & Hypotheses Research Question:• What is the impact of occupational therapy low

vision rehabilitation on the occupational performance of older adults with low vision?

• Hypothesis1: Older adults with low vision who receive occupational therapy low vision rehabilitation will demonstrate more independence in their occupational performance skills, such as mobility, reading and writing, and activities of daily living.

• Hypothesis2: Older adults with low vision who receive occupational therapy low vision rehabilitation will report improvements in their quality of life as measured by the Low Vision Quality of Life (LVQOL) questionnaire.

Research Design

• An ABA single case study design was used to determine the effectiveness of low vision training on occupational performance among older adults with low vision.

• This pretest-posttest design with low vision rehabilitation intervention occurred 1 time per week for 4 weeks.

• This design was used to (1) establish the level of functioning before low vision training, (2) to monitor and make adaptations during low vision training, (3) and to track the change in function after the intervention was completed.

Participants• A convenience sample of 6 participants diagnosed

with low-vision disorders were recruited from Howard University Hospital, Department of Ophthalmology, Low Vision Clinic for this study.

• All participants met the inclusion criteria that consisted of (1) 50 years of age or older, (2) diagnosis of low vision impairment (worse than 20/70 but no worse than 20/400 visual acuity in the better-seeing eye, (3) No evidence of severe cognitive deficits or dementia, (4) English language fluency, and (5) potential or current use of low vision assistive devices.

• Signed consent forms were required of all volunteer participants. The study protocol and consent forms was submitted to and approved by Howard University Institutional Review Board.

Instrumentation• A questionnaire consisting of 25 questions was

developed by the Victorian College of Optometry. The 25-item Low Vision Quality of Life Questionnaire (LVQOL) was used to measure the impact of visual impairment on aspects of daily living, such as self care, mobility, reading and fine work, and quality of life.

• Each of the questions in the questionnaire were written in large print to address the participants’ visual impairment. Assistive technology for text magnification was available if needed.

Instrumentation(continued)

•The LVQOL addresses issues related to quality of life reduction in those with low vision and is able to quantify the benefit of low-vision rehabilitation (Wolffsohn, 2000).

•The Low Vision Quality of Life Questionnaire has a high internal consistency (= 0.88) and good reliability (0.72).

Procedures•Participants were recruited through clinic

referrals from the Howard University Hospital, Departments of Ophthalmology and Optometry, Washington, DC to their Department of Ophthalmology Low Vision Rehabilitation Clinic.

• Under the direct supervision of a registered occupational therapist, the student researchers introduced and explained the purpose of the study, and administered the questionnaire before and after the intervention.

Procedures included:

Data Collection•An initial evaluation was performed using the

Columbia Lighthouse for the Blind evaluation form, which is specifically geared toward persons with low vision.

•The LVQOL was administered to the participants in low vision clinic before their rehabilitation and a second LVQOL was administered upon discharge from low vision rehabilitation services.

•Six participants completed the initial pre test assessment; one person did not complete the post test and was removed from the study. The overall response rate was high, 83%, supporting the importance of low vision rehab.

Data Analysis•A t-test design was used to analyze the data

and determine if there was a statistically significant difference in occupational performance and quality of life means before and after the intervention.

•Analysis of the occupational performance and quality of life data was performed using the Statistical Package for the Social Science (SPSS) 17 software (SPSS Inc., Chicago, Illinois). For the purposes of validation and reliability, the data was entered twice to lower the error rate of the recorded survey information.

Results• A total of 5 participants (3 females and 2 males) were a part of this study. The majority of the participants were between the ages of 50-60 years of age (60%), the remaining participants were between the ages of 61-70 years of age (40%). Of the participants, 20% have had low vision for 6 months – 2years, 40% for 2-7 years, and 40% for 7 years or more. Of the participants, 2 participants work full-time jobs, 1 participant works part-time, and 2 participants are retired and do not work outside the home.

Figure 1. represents the percentages of the study participates and their visual diagnoses

Results

Visual difficulty with distance vision, mobility, and lighting show improvement between

the pre and post for all 5 participants. Note that all 5 participants reported some tangibleimprovement in distance vision, mobility or lighting post treatment.

This is a critical area because it creates the backdrop for all other areas of functioning.

Results

Reading and fine work showed a mean increase from pretest to posttest for all participants. Occupational performance showed the

greatest improvement in performance per participant. Increases made for participants 1, 2 and 3 were significant at p=<.05.

Results

Occupational performance in activities of daily living showed a mean increase between the pre and posttest for all participants. Significance was shown only for Person 2. This area is of great significance in occupational

performance because it is the foundation of occupational therapy.

Results

All 5 participants reported a better quality of life as a result of low vision rehab intervention. While persons 4 and 5 showed the lowest minimum

increase between pretest and posttest, the other 3 participants reported a significantly more positive difference in their quality of life following low

vision rehabilitation.

Discussion• Appropriate hypotheses & research questions were

pursued. Occupational performance and quality of life improvements suggest outcomes were a result of clients participation in occupational therapy low vision rehabilitation services.

• Opportunities for future research could include:▫Exploration of other models of low vision

rehabilitation research.▫Elements of rehabilitation programs, such as

number of clinic visits, remain critical in order to explore strategies that improve the quality of life.

Limitations to this Study

•Very small sample size•Limited access to assistive devices for use

at home by clients followed their discharge from clinic setting.

•Exploration of grant availability is underway that might facilitate purchase of assistive products found useful by clients who are seen in this clinic.

References

• Babbie, E. (2004). The Practice of Social Research, Tenth Edition. Belmont California:Thomson / Wadsworth Learning.

• Copolillo, A. T. (2005). Aquisition and integration of low vision assistive devices: Understanding the decision-making process of older adults with low vision. American Journal of Occupational Therapy, 59, 305-313.

 • Culham, L. R. (2002). Low vision services for vision

rehabilitation in the United Kingdom. British Journal of Ophthamology, 86, 743-747.

References(continued)• Girdler, S. P. (2008). The Impact of Age-Related Vision Loss. Occupational Therapy Journal ofResearch, 110-120. • Hinds, A. S. (2003). Impact of an interdisciplinary low vision

service on the quality of life of low vision patients. British Journal of Ophthamology, 87, 1391-1396.

 • International, L. (2001). The Lighthouse National survey on

vision loss: The experience, attitudes & knowledge of middle-aged and older Americans. Retrieved November 7, 2008, from http://www.lighthouse.org/pubs_lhsurvey_findings.htm

 • La Grow, S. (2004). The effectiveness of comprehensive low

vision services for older persons with visual impairments. Journal of Vision Impair Blindness, 98(11), 679-692.

References (Continued)

• Leat, S. (2004). Outcome of low vision aid provision: the effectiveness of a low vision clinic. Optometry Vision Science, 71, 199-206.

• Mogk, L. (2007). Eye conditions that cause low vision in adults. In G. Goodrich, Low Vision Self-paced Clinical Course (pp. 25-43). New York: Ballantine.

• Shuttleworth, G. (2005). How effective is an integrated approach to low vision rehabilitation? British Journal of Ophthalmology, 79, 19-23.

 • Stelmack, J. (2008). Outcomes of the Veterans Affairs Low

Vision Intervention Trial (LOVIT). Archives of Opthamology, 126, 608-617.

References(continued)• Tielsch, J. (2000). The epidemiology of vision impairment. In B.

L. Silverstone, The lighthouse handbook on vision impairment & vision rehabilitation (pp. 5-17). New York: Oxford University Press.

• Warren, M. (2006). Employing occupational therpists to assist the low-vision population. American Journal of Occupational Therapy, 72-73.

• Wolffsohn, J. C. (2000, June). Design of the low vision quality of life questionnaire (LVQOL) and measuring the outcome of low-vision rehabilitation. American Journal of Ophthalmology, 793-802.

 • Wormald, R. W. (1992). Visual problems in the elderly

population and implications for services. British Medical Journal, 304, 1226-1228.

 

Acknowledgements• Robert A.Copeland Jr., M.D., Chair, Howard

University Hospital (HUH), Opthamology Dept.

• Heidi Bowie, O.D., Optometrist , HUH Low Vision Rehabilitation Services Coordinator

• Mrs. Shirley J. Jackson, MS, OTR/L, FAOTA, Howard University Faculty, Student Research Advisor

• Anne Morris, Ed.D., OTR/L, FAOTA, Howard University Faculty, OT Supervisor, HUH Low Vision Rehabilitation Clinic

• Felecia Banks, Ph.D. OTR/L, Howard University, Chair, Occupational Therapy Department

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