occupational therapy & vision rehabilitation presented by: margaret a. waskiewicz ms, otr/l unit...
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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.