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
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Physiatrist
Internal Medicine
Nurses
Ophthalmologist
Neuro-optometrist
Occupational Therapist
Physical Therapist
Speech Therapist
Psychologist /Social Worker
Additional professionals includeOrientation 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
Warren 2009
Visual Impairment: Can occur secondary
to illness, trauma, and age
Disease/Condition:
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Parkinson’s
Multiple Sclerosis
Degenerative myopia
Diabetic retinopathy
Glaucoma
Optic Nerve Trauma / Atrophy
Stargardt’s disease
Degenerative myopia
Trauma:
Stroke
Traumatic Brain Injury
Aquired Brain Injury
Age:
Cataracts
Age 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 and
Errors 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 PRINCIPLES
FOR
ENHANCING
VISUAL 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
R
D. ENLARGE: make things BIGGE
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 material
Client 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 environment
Therapy 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 2011
Evidenced based review of Visual Scanning
Training (VST) and developing skills
A compensatory strategy
Considered 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
*** Changes in Perception
Diplopia:
double vision
blurring of vision
ghosting images
distortion
This interferes with object identification
Creates visual stress
Can impair reading performance
Almost 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: agerelated 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 vision
20/500 to 20/1,000: profound visual impairment
or profound low vision
More than 20/1,000 : near-total visual
impairment or near total
blindness
No 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
RESOURCES
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.
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.