Transcript hospital/institute/center

Occupational Therapy &
Vision Rehabilitation
Presented by:
Margaret A. Waskiewicz MS, OTR/L
Unit 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: Background
Patient 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
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Case Study #1: Initial Presentation
Physically
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
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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
fasteners
LB: 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
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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.”
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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
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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
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Activity Log
Activity
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”
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Case Study #1: Standardized Assessments
Pre and Post
9 hole peg
Initial
Discharge
RUE: 59.03 s
(Norm 17.8 s)
RUE: 24.2 s
LUE: 17.56 s
LUE: 39.28 s
(Norm 19.4 s)
Convergence
9 inches
6 inches
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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/buttons
LB: 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
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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.”
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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
Who Is Involved?
•Occupational Therapist
•Neuro-ophthalmologist
•Neuro-optometrist
•Physiatrist
•Other rehab services
•PT
•Vestibular PT
•SLP
•Neuropsychology/psychology
•Nursing
•Social work
•Vocational rehab
Conclusion
•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.
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.