Chapter 4 VISION ASSESSMENT AND INTERVENTION

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Vision Assessment and Intervention

Chapter 4

VISION ASSESSMENT AND INTERVENTION

SHARON GOWDY WAGENER, OTR/L, BA, MAOT*; MATTIE ANHELUK, MOT, OTR/L†; CHRISTINE ARULANANTHAM, BOT, OTR/L‡; and MITCHELL SCHEIMAN, OD§

SECTION 1: VISION ASSESSMENTINTRODUCTIONSYMPTOM SELF REPORT: COLLEGE OF OPTOMETRISTS IN VISION

DEVELOPMENT QUALITY OF LIFE ASSESSMENTDYNAMIC FUNCTIONAL TASK OBSERVATION: VISION DISTANCE VISUAL ACUITY TESTINGACCOMMODATIVE AMPLITUDE TESTNEAR POINT OF CONVERGENCEBINOCULAR VISION: EYE ALIGNMENT TESTSACCADES: DEVELOPMENTAL EYE MOVEMENT PURSUITS AND SACCADES: NORTHEASTERN STATE UNIVERSITY COLLEGE OF OPTOMETRY TESTCONFRONTATION FIELD TESTSTEREO RANDOT TEST BRAIN INJURY VISUAL ASSESSMENT BATTERY FOR ADULTS

SECTION 2: VISUAL INTERVENTION INTRODUCTIONPOOR ACUITY IMPAIRED PURSUITS IMPAIRED SACCADES IMPAIRED ACCOMMODATION IMPAIRED CONVERGENCE DIPLOPIA VISUAL FIELD LOSS VISUAL NEGLECT AND INATTENTIONGLARE SUPPLEMENTARY THERAPEUTIC ACTIVITY OPTIONS

REFERENCES

* Occupational Therapist, Instructor Scientist, Rehabilitation Services, Courage Kenny Rehabilitation Institute/Abbott Northwestern Hospital, 800 East 28th Street, Mail Stop 12213, Minneapolis, Minnesota 55407

† Occupational Therapist, Instructor Scientist, Comprehensive Outpatient Rehabilitation, Courage Kenny Rehabilitation Institute, United Hospital–Occupational Therapy Department, 33 North Smith Avenue, Saint Paul, Minnesota 55102

‡ Occupational Therapist, Instructor Scientist, Rehabilitation Services, Courage Kenny Rehabilitation Institute/Mercy Hospital, 4050 Coon Rapids Boulevard, Coon Rapids, Minnesota 55433

§ Professor, Associate Dean of Clinical Research, Pennsylvania College of Optometry at Salus University, 8360 Old York Road, Elkins Park, Pennsylvania 19027

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Mild TBI Rehabilitation Toolkit

Figure 4-1. Segments in progressive lenses.

SECTION 1: VISION ASSESSMENT

INTRODUCTION

• Makesurethepatientisseatedcomfortablywithhisorherheadverticallyerect.

• If thepatient iswearingglasses, ensuretheyfitproperlyandthatthepatientusestheappropriatesectionoftheglassesforthetask(Figure4-1).

° Upperportionofthelensisfordistance. ° Trifocalformid-distance(18–24inches),

suchasacomputermonitor. ° Lowerportion forneardistance (~16

inches),forexample,readingdistance. ° Somepeoplewearprogressive lenses

thatdonothaveobvioussegments,butplacementshouldbesimilar.

• Another factor to consider is thatmanypeoplearenowusingmonovisioncontacts:oneeyeisusedfordistanceandtheotherfornearvision.Besuretoaskaboutthisandadaptyourassessmentaccordingly.

Assessment Sequence and Methods

• Begintheassessmentwithaquestionnaireofsymptomstohelpdetermineifandhowthepatientisexperiencingvisualstressorimpairment.

• Itisalsopossibletopiecetogethertheareasofassessmentwithavarietyoftests.Theorderofassessmentshouldfollowthatoftheabovelistasitmovesfrombasicvisualcomponents tomore complex tasks (ie,startwithacuitytodetermineifthepatientisabletoseefunctionallytoparticipate).

Vision is themost far-reachingofour sensorysystems.Changestothissystemcanaffectpatients’abilitytoparticipateintherapyaswellastofunctionineverydaylife.1Combattroopswithblast-relatedconcussion/mildtraumaticbraininjury(c/mTBI)are at risk forvisualdysfunction.2Occupationaltherapists are often the first-line clinicianswhocanidentifyvisualimpairment.Theoccupationaltherapist’srolesincludethefollowing3:

• evaluatingvisionfunctionthroughvisionscreeningandfunctionalobservations.

• determiningifandhowvisualimpairmentmaybeaffecting thepatient’s functionalperformance.

Ifvisualimpairmentissuspected,theoccupationaltherapist:

• refersthepatienttothestaffoptometristwith expertise in vision and traumaticbraininjury(TBI)orneuro-ophthalmolo-gistforfurtherevaluationandinterventionmanagement,

• educatesthepatientandtherehabilitationteamabouthowtheimpairmentisaffect-ingthepatientfunctionally,and

• providesbothcompensatoryandremedial(incollaborationwithanoptometrist)treat-ment,asappropriate.

Occupational therapists provide a basic visionscreeningthatincludesthefollowingelements:

• symptomquestionnaire, • visualacuity, • visualfields, • ocularmotor(pursuits,saccades,conver-

gence), • binocularvision,and • glare/photophobia.

The specific screening tool ormethodusedwillbedictatedbyavailableresourcesandtherapist’sexpertiseandpreferences;assessmentsincludedinthetoolkitareconsideredoptions.

General Instructions for Vision Assessment

• Setupinawell-lit,glare-andclutter-freeroom.Minimaldistractions(physical,vi-sual,orauditory)areoptimal.

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• Theoccupationaltherapistobserveshowthepatient isusinghis orher eyes andthefunctionalimplications.Thetherapistshouldlookforthefollowing:

° facial expressions, head turning orslanting,squinting;

° fatigue, frustration, complaints ofheadaches,etc;

° complaintsoflosingone’splacewhenreading;

° qualityofeyemovements; ° smoothversusjerkymovements; ° eyesmissingorlosingthetargets;and ° over-andundershooting.

Thesesymptoms,alongwiththepatient’sabilitytoperformthetasksortests,willhelptheoccupa-tional therapistdeterminewhether thepatient isexperiencingvisualimpairment.

General Equipment to Have on Hand

• Occludersoreyepatches • Penlight • Ruler • Penandpaper • Dowelswithsmallballsorobjectsattached

totheends

Preferred Methods

Becausethevisualsystemiscentraltoparticipa-tion in therapyandfunctioning ineveryday life,occupationaltherapistsperformavisionscreenonservicememberswithTBI to identify suspecteddeficits,refertovisionspecialists,andbetterunder-standpatients’functionalperformanceproblems.Theutilityofthisprocess,however,isimpededbythefactthatthereisnogoldstandardforavisionscreenonadultswithTBI.This issuewill be re-solvedifandwhenpsychometricdataarecollectedandpublishedonthispopulation.Toaddresstheneedtospecifypreferredpractices

untilsuchtime,aconsensuspanelcomprisedofoc-cupationaltherapyandoptometryvisionexpertswasconvenedinJuly2011bytheUSArmyOfficeoftheSurgeonGeneral—RehabilitationandRein-tegrationDivision.Thepanelwas chargedwithexaminingexistingoptionsandusingamodifiedDelphi process to achieve consensus as to thecompositionofabriefoccupationaltherapyvisionscreenforSMswithc/mTBI(Table4-1);thetoolsandmethodsconsideredarefurtherdescribedinthis chapter.Note that, likemost assessments inthis section,methodsendorsedby thepanel areconsideredpractice optionsbecausetheyhavenotbeenfullyevaluatedonadultswithc/mTBI;how-ever,giventheirselectionfrommanyalternatives,

TABLE 4-1

RECOMMENDED COMPONENTS OF VISION SCREEN

Components of Vision Screen* Corrective Lenses Use During Testing

Functionalperformance/behavioralvisionchecklistconcurrent SMwearscorrectivelenses(ifappropriate) withorcomplementarytotestsSymptomself-report:COVD-QOLOutcomesAssessment+ photosensitivityinterviewquestionFar/nearacuity:CPACAccommodation:AccommodativeAmplitudeTestConvergence:nearpointofconvergenceEyealignment&binocular:eyealignmenttestSaccades:A-DEMPursuits:NSUCO SMistestedwithouthis/hercorrectivelensesConfrontation:fingercounting

*InorderofadministrationA-DEM:AdultDevelopmentalEyeMovementTestCOVD-QOL:CollegeofOptometristsinVisionDevelopmentQualityofLifeAssessmentCPAC:ChronisterPocketAcuityChartNSUCO:NortheasternStateCollegeofOptometryEyeMovementTestSM:servicemember

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thosemethodsrecommendedbythepanelmightbeconsidered“better”practiceoptions.Donotunder-

Additional Resources for Occupational Therapy and Vision

Gillen G. Cognitive and Perceptual Rehabilitation: Optimizing Function.StLouis,MO:Mosby;2009.

ScheimanM.Understanding and Managing Vision Deficits: A Guide for Occupational Therapists. 3rded.Thorofare,NJ:SLACKIncorporated;2011.

ZoltanB.Vision, Perception, and Cognition: A Manual for the Evaluation and Treatment of the Adult With Acquired Brain Injury.4thed.Thorofare,NJ:SLACKIncorporated;2007.

SYMPTOMS SELF-REPORT: COLLEGE OF OPTOMETRISTS IN VISION DEVELOPMENT QUALITY OF LIFE ASSESSMENT

afterintervention.Patientsrateeachstatementona0-to-4scale(with0indicatingthatthesymptomisneverpresentand4indicatingthesymptomisalwayspresent).Thequestionnaire is tobecom-pletedby thepatient or therapist via interviewwith patient, familymembers, and caregivers.Administrationtimeis lessthan10minutes.Thequestionnaire is available atno cost and canbeobtainedbycontactingtheCollegeofOptometristsinVisionDevelopment (215WestGarfieldRoad,Suite200,Aurora,OH44202).

Groups Tested With This Measure

TheCOVD-QOLAssessmenthasbeenusedinchildrenandadultswithvarious typesofvisiondisorders.Diagnoses including strabismus, am-blyopia,TBI,autismspectrum,sportsvision,visionskills,visionperception,andreadingdysfunctionwereincludedinamultisitestudy,whichconcludedthatpatientsreportedsignificantlyfewersymptomsaftervisiontherapyusingtheCOVD-QOLAssess-ment.6Shin,Park,andPark7usedtheCOVD-QOLAssessmentwithparentsandtheirchildrenages9 to 13years old to explore theprevalence andtypesofnonstrabismicaccommodativeorvergencedysfunctions.Farrar,Call,andMaples8comparedthe visual symptoms between attentiondeficitdisorder (ADD)/attentiondeficit-hyperactivitydisorder (ADHD)andnon-ADD/ADHDchildren.There is no literaturedescribing theuse of theCOVD-QOLAssessmentinadultswithc/mTBI.

Interpretability

• Norms:notavailable • Minimaldetectablechange95%(MDC95):

0.193 for the itemmean score on the

Purpose/Description

TheCollegeofOptometrists inVisionDevel-opmentQualityofLifeOutcomes(COVD-QOL)Assessmentwasdeveloped in 1995 to describeandmeasurechangesresulting fromoptometricintervention, including vision therapy. This 30-item,self-reportsurveyaddressesfourareas:(1)physical/occupationalfunction,(2)psychologicalwell-being,(3)socialinteraction,and(4)somaticsensation.Theshortform,theS-COVD-QOL,in-cludes19itemsandtest-retestreliabilitysuggeststhe short form is a satisfactory substitute.4Thisassessmentmay be used to identify problems,provide treatment, andmake referrals. It isnot intendedtoreplaceacomprehensivevisionevalu-ationbyanoptometrist.Thequestionnairemaybeahelpfulinclusionin

aninitialoccupationaltherapyevaluationwhen:

• thepatienthasnothadacomprehensivevisual assessment by an optometrist orophthalmologisttoidentifyvisualimpair-ments,and

• the patient hasmild-to-moderate braininjury or c/mTBI, and observation offunctionalperformancesuggeststhepos-sibilityofvisualdysfunctioninanumberofdomains.

Thisquestionnaireshouldbeusedinconjunctionwithafullvisionscreen.

Administration Protocol/Equipment/Time

Maples5 recommendeduseof this assessmentatoptometricinitialassessment,duringtherapy,atcompletionoftherapy,andatapredeterminedtime

estimatetheimportanceofyourownobservationskillsandlookforfunctionalimplications.

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COVD-QOL. This means a patient’sposttreatmentscoreneedstochangebyatleast.193fromthepretreatmentscoreforthe30itemstobe95%confidentthattruechangeoccurred(ratherthanmea-surement error).MDC95was calculatedbasedonMaples.5

• Responsivenessestimates:notavailable

Reliability Estimates

• Internalconsistency:notavailable • Interrater:notavailable • Intrarater:notavailable • Test-Retest:Maples5determinedtest-retest

by testing 19 optometry studentswithadministrations separated by 2weeks.WilcoxonSignedRankAnalysisshowednosignificantdifferences.Apairedt-testand item analysiswere insignificant.Spearman’srhocorrelationfortest-retestofeachsubjectwas0.878.Intotal,89%ofsubjects scored insignificantlydifferent,

while 90%of itemswere found tovaryinsignificantly.

Validity Estimates

• Content/Face:notavailable • Criterion:notavailable • Construct: Daugherty, Frantz,Allison,

andGabriel9 demonstratedquality-of-lifechangesaftervisiontherapywithsubjectsdiagnosedwith binocular visionwhoranged from7 to45yearsof age.WhiteandMajor10comparedsubjectswithcon-vergence insufficiencyand subjectswithnormalbinocularvisionusing thismea-sureandfoundtwoofthe30itemswerestatisticallyhigherforconvergenceinsuf-ficiencythanfornormalbinocularvision.Farrar,Call,andMaples8comparedthevi-sualsymptomsbetweenADD/ADHDandnon-ADD/ADHDchildrenandnotedthat14ofthe33symptomsweresignificantlymoresevereintheADD/ADHDgroup.

Selected References

DaughertyKM,FrantzKA,AllisonCL,GabrielHM.EvaluatingchangesinqualityoflifeaftervisiontherapyusingtheCOVDQualityofLifeOutcomesAssessment.Optom Vis Dev.2007;38:75–81.

MaplesWC.Test-retestreliabilityoftheCollegeofOptometristsinVisionDevelopmentQualityofLifeOutcomesAssessmentShortForm.J Optom Vis Dev.2002;33:126–134.

MaplesWC.Test-retestreliabilityoftheCollegeofOptometristsinVisionDevelopmentQualityofLifeOutcomesAssessment. Optometry.2000;71(9):579–585.

DYNAMIC FUNCTIONAL TASK OBSERVATION: VISION

toanindividual’sgoalsandtodetermineunderwhichcircumstancesthepatient’sperformanceisoptimized.Occupationaltherapistsdesignpatient-relevantfunctionaltasksanduseanobservationworksheet, like theDynamic Functional TaskObservationChecklist(Form4-1),toanalyzetaskandenvironmentalcharacteristicsandtocatalogtheassociatedpersonalcharacteristicsandoverallperformance.

Recommended Instrument Use: Practice Option

TheDynamic Functional TaskObservationChecklistmaybeusedtostructurepatientperfor-manceobservationsduringtheassessmentphaseandthroughouttheepisodeofcare.

Purpose/Description

Functional taskobservation is a critical com-ponentofacomprehensivecognitiveandvisualassessment.Manystandardizedtestsdonotposethe same challenges to patients as trying tofunction inunstructuredtasksorenvironments;therefore, systematic observation of functionaltaskperformanceprovidesuniqueopportunitiesto further understandpatients’ challenges andstrengths.Byobservingpatientsastheyperformfunctionaltasks,occupationaltherapistsassesstheextenttowhichtask,environment,andpersonalcharacteristics interact to impact performance.Furthermore, therapistsmodify task and envi-ronmentalvariablestoright-fitchallengesspecific

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FORM 4-1

SISTER KENNY DYNAMIC VISUAL TASK OBSERVATION CHECKLIST

(Form 4-1 continues)

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Form 4-1 continued

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onanygroups.Thisdescriptionproposesmethodsbywhichoccupationaltherapistscanstandardizeobservationaltasksfortheirownuse.

Interpretability

• Norms:Therearenonormsforthispro-cess, but as individual therapists craftand frequently use a core set of obser-vational tasks, theywill readily identifyabnormalities,errors,ordiscrepancies inperformance.

• MDC:notapplicable • Responsivenessestimates:notapplicable

Reliability and Validity Estimates: notapplicable

DISTANCE VISUAL ACUITY TESTING

allthelettersonthe20/40line(notethe“40” in lower left corner of the chart).

• Topass the screening, thepatientmustbeabletocorrectlyreadthreeofthefour20/40letters.Patientswhofailthescreen-ingshouldbereferredtoavisionspecialist(emailcommunication,MitchellScheiman,OD,Chief,Pediatric/BinocularVisionSer-viceandProfessor,SalusUniversity,TheEyeInstituteofthePennsylvaniaCollegeofOptometry,Philadelphia,PA, January12,2012).Itisunnecessaryforthepatienttoreadthelargerlettersunlessthetherapistwantstodetermineexactvisualacuity.

• Ifthepatienthasproblemsreadingletters,visualacuitymaybeassessedusingtheLeaSymbolsTest(Good-LiteCo,Elgin,IN).

Groups Tested With This Measure: notavailable

Interpretability

• Norms:Expecttoseeatleast20/40withbotheyestogether.

• Although20/20visualacuityisconsidered“normal,”inascreeningformatitisonlynecessarytodeterminewhetherapatienthasa lossofvisualacuitythatmight in-terferewith function; thus, forscreeningpurposes,visualacuityworsethan20/40isusedasthecriterionforreferral.

• MDC:notapplicable • Responsivenessestimates:notapplicable

Reliability and Validity Estimates: notavailable


Thesedimensionsvarydependingonthetaskdevelopedbytheclinician.SeeChapter9,Perfor-mance andSelf-Management,Work, Social, andSchoolRoles, for examplesofvision-demandingtasks,includingthefollowing:job-specifictacticalsimulation1 (dynamicvisual scanningactivity),job-specific tacticalsimulation2(targetdetectiononvisualscanningactivity),class-Aerrordetection,topographicalsymbolsonamilitarymap,andgridcoordinatesofapointonamilitarymap.


Thesemethodshavenotbeen formally tested

Purpose/Description

Distancevisualacuitytestingisusedtodeter-mine thepatient’sability to focusonanddistin-guishfinedetailatadistanceof20feet.



EquipmentrequiredincludesChronisterPocketAcuityChart(CPAC;GuldenOphthalmics,ElkinsPark,PA),aflip-pocketchartof22pagesoftargets.

Setup

• Provideadequatelightingonthetestcard. • Glassesorcontactsshouldbewornduring

testingifthepatientnormallywearsthem.Makesurethepatientusestheappropriateglassesandportionoftheglassesforthetest(ie,ifheorshehasbifocal,trifocals,orprogressivelenses;seeFigure4-1).

• Although visual acuity is traditionallymeasuredwithoneeyecovered,itisrec-ommendedthatthepatientkeepsbotheyesopenduringtesting,asthegoalistode-termineifthereisavisualacuityproblemthatcouldinterferewithhowthepatientfunctionswithbotheyesopen.

Administration Protocol

• PositiontheCPAC20feetawayfromthepa-tient.Instructthepatienttoverballyidentify

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Selected Reference


ACCOMMODATIVE AMPLITUDE TEST

onlyprescribed for reading, theyshouldnotbeusedforthistest.Inaddition,ifthepatientwearsabifocalorprogressivelens,thepatient’s accommodative amplitudemustbemeasuredthroughthetopportionoftheglasses, notthereadingportionoftheglass.

• Makesurethereisnoglareandthatillu-minationisadequate.

• Positionthepatienttooptimizeattention.

Testing • Placepatchoverthepatient’slefteye. • Hold the fixation stickwith the 20/30

targetabout1inchinfrontofthepatient’srighteye(usethesmallsingleletterontopofthestick).

• Slowlymovethefixationstickawayfromtheeyeuntil thepatientcan identify theletter(itdoesnothavetobeperfectlyclear).

• Measuredistancefromeyetotargetwhenthepatientcanidentifytheletter.

Scoring • Recordthedistancefromthepatient’seye

tothetargetwhenthepatientcanidentifytheletter(Exhibit4-1).

• Divide40bythisnumbertodeterminethepatient’samplitudeofaccommodation(eg,ifthepatientcanseetheletterat8inches:40÷8=5D).

• Usenormstablestointerpretresults(seeInterpretability).


Greenetal12usedthepush-upaccommodativeamplitudemethodasameasureofaccommoda-tionwhentesting12adultpatientswithc/mTBIcompared to 10 control subjectswithnovisualimpairment.Asignificantdifferencebetweenthemeanpush-upaccommodativeamplitudeswasin-dicatedforsubjectswithc/mTBIwhencomparedtoage-appropriatenormativevalues.Conclusionsindicated use of the push-up accommodativeamplitudemethodasavisualscreeningtoolfor

Purpose/Description

Accommodative amplitude is defined as the“closestnearfocusingresponsethatcanbeproducedwithmaximalvoluntaryeffortinthefullycorrectedeye.”11(p128)Anaccommodative amplitude screenmaybeusedtoidentifyproblems,providetreatment,andmakereferrals.Itisnotintendedtoreplaceacomprehensivevisionevaluationbyanoptometrist.

Recommended Instrument Use: Practice Standard

Thistestmaybeahelpfulinclusioninaninitialoccupationaltherapyevaluationwhen:

• thepatienthasnothadacomprehensivevisual assessment by an optometrist orophthalmologisttoidentifyvisualimpair-ments,and

• the patient hasmild-to-moderate braininjury or c/mTBI and observation offunctionalperformancesuggeststhepos-sibilityofvisualdysfunctioninanumberofdomains.

Thistestcanbeusedinconjunctionwithafullvi-sionscreentoassessforaccommodationproblems.


See below for themodifiedpush-upmethodinstructions.Administration time is less than 2minutes.Equipmentneedsincludea fixationsticksuchastheGuldenfixationstick,eyepatch,andruler.Positioningisimportantandtheoccupationaltherapistshouldtrytofindthebestpositionthatpermitsthepatienttoattendandconcentrateonthetask.Thepatient’sheadwill ideallybeverticallyerect. If thepatientwears corrective lenses, theyshouldbeusedduringthistest.

Modified Push-Up Method

PreliminarySteps • Ifglasseshavebeenprescribedforbothfar

andneardistance, theglasses shouldbewornforthistest;however,ifglasseswere

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hospital technical and therapy staff, including occupational therapists. Chen andO’Leary13 showedhighreliabilitybetweentheconventionalandmodifiedpush-upmethodstestingchildrenandadults.Rouse,Borsting,andDeland14evalu-ated interrater and intrarater reliability of themonocular push-up accommodative amplitudewithchildrenandfoundreliabilityrepeatableinchildren.

Interpretability

• Norms: Hofstetter created formulas fortheexpectedmeanaccommodativeampli-tudesbasedonnormativedataofDuaneandDonders.11(p396)

• Expectedmeanamplitude:18.5D–[0.30D×(ageinyears)].Also,seeScheiman15forexpectedvaluesof amplitudeof accom-modationbyage.

• Ifthepatient’samplitudeofaccommoda-tionismorethan2Dbelowtheexpectedfinding, it is considered aproblem. If apatient’s amplitude of accommodationis greater than expected, it suggests thepatienthasexcellentaccommodation.

• MDC:notavailable • Responsivenessestimates:notavailable


• Internalconsistency:notavailable • Interrater:Goodinterraterreliabilitywith

childrenindicatedbyintraclasscorrelation(ICC)ranges0.81to0.85.14

• Intrarater:Intraraterwithin-sessionreliabil-itywasexcellentwithchildrenwithICC’s≥0.88.14Rouseandcolleaguesalsodeter-mined fair-to-good between-session in-traraterreliabilitywithICC0.89and0.69.14

• Test-Retest:Repeatabilityofthemodifiedpush-upmethod for twooccasionswashigh for bothmonocular andbinoculartestingwithyoungadultsubjects.13

Validity Estimates

• Content/Face:notavailable • Criterion:ChenandO’Leary13compared

themodifiedpush-uptotheconventionalpush-upmethodwithchildrenandadultsubjects and found the tests tobe inter-changeable.

• Construct:Greenetal12foundsignificantdifference between themean push-upaccommodative amplitudes for subjectswith c/mTBIwhen compared to age-appropriatenormativevalues.

Selected References

ChenAH,O’LearyDJ.Validityandrepeatabilityofthemodifiedpush-upmethodformeasuringtheamplitudeofaccommodation.Clin Exp Optom. 1998;81:63–71.

GreenW,CiuffredaKJ,ThiagarajanP,SzymanowiczD,LudlamDP,KapoorN.Accommodationinmildtraumaticbraininjury.J Rehabil Res Dev.2010;47(3):183–199.

ScheimanM.Understanding and Managing Vision Deficits: A Guide for Occupational Therapists.3rded.Thorofare,NJ:SLACKIncorporated;2011.

EXHIBIT 4-1

ACCOMMODATION RESULTS

Distanceatwhichpatientcanidentifyletter:inches

40/(#ofinches)=40/=D*(amplitudeofaccommodation)

Possibleimpairmentofaccommodation:Yes No*Comparethisresultwiththeexpectedamplitudeofaccommodationbyage.Expectedmeanamplitude:18.5D–[0.30D×(ageinyears)]or,forexpectedmeanamplitude,seeScheimanM.Understanding and Managing Vision Deficits: A Guide for Occupational Therapists.3rded.Thorofare,NJ:SLACKIncorporated;2011.

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NEAR POINT OF CONVERGENCE

tientateyelevel.Askifthepatientseesonepencilorpenlight.Ifnot,movethepencilorpenlightfurtherawayuntilthepatientseesonepencil.

• Slowlymovethepenciltiporpenlightto-wardthepatientateyelevelandbetweenthepatient’seyes.

• Instructthepatienttokeephis/hereyesonthetipofthepencilorpenlightforaslongaspossible.

• Ask thepatient to tellyouwhenhe/sheseesasplitimage(ie,twopenciltips).

• Oncediplopiaoccurs,movethepenciltip orpenlighttowardthepatientanotherinchortwoandthenbegintomoveitaway.

• Askthepatienttotrytosee“one”again. • Watch the eyes carefully and observe

whethertheystopworkingtogetherasateam.Oneeyewillusuallydriftout.

Scoring

The therapist should record thedistance (ininches) between thepatient andpencilpoint or penlight atwhich thepatient reportsdoublevi-sionandthedistanceatwhichthepatientreportsrecoveryofsinglevision(Exhibit4-2).

Normal performance. Whentheeyeslosealign-ment,itisreferredtoasa“break.”Whenabreakoccurs,onewilleyedriftoutward,andwhenthepatientrecoversfusion,theeyeswillmovebackintoalignment.15Patientswithnormalconvergencewillreportdoublevisionandlosealignmentwhenthepenciltiporpenlightmovestowardthemtowithin2to4inchesoftheireyes.15Thosewithnormalcon-vergenceswillrecoversinglevisionwhenthetargetis4to6inchesasitismovedawayfromthem.15

Abnormal performance. Patientswithsignifi-cantproblemswithbinocularvisionmayormaynot actually reportdouble visionbecause some

Purpose/Description

Convergenceisdefinedastheabilitytomaintaineyealignmentasanobjectapproachestheeyes.Thistestofnearpointconvergence(NPC)maybeusedtoidentifyproblems,providetreatment,andmakereferrals.Itisnotintendedtoreplaceacomprehen-sivevisionevaluationbyanoptometrist.

Recommended Instrument Use: Practice Standard


• thepatienthasnothadacomprehensivevisual assessment by an optometrist/ophthalmologisttoidentifyvisualimpair-ments,and

• the patient hasmild-to-moderate braininjuryorcomplicatedc/mTBIandobser-vationoffunctionalperformancesuggeststhepossibilityofvisualdysfunction inanumberofdomains.

Thistestcanbeusedinconjunctionwithafullvisionscreentoassessforconvergence.


Equipmentneededincludesapenlightorpen-cilandaruler.Administrationtimeislessthan2minutes.

Procedure

• Standorsitfacetofacewiththepatientinalocationthatoptimizesthepatient’sabilitytoattendtothetask.

• Beginwiththepencil tiporpenlightap-proximately12inchesawayfromthepa-

EXHIBIT 4-2

NEAR POINT OF CONVERGENCE RESULTS

Breakingpoint*:_____Recoveryoffusion†:_____Possibleimpairmentofconvergence: Yes____ No____*Asidentifiedbypatientorobservationofbreakbytherapist,clinicalcutoffvalueof5cmor~2inches†Asidentifiedbypatientorobservationofeyerealignmentbytherapist,clinicalcutoffvalueof7cmor~3.5inches

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maybeable to suppress the eye that turnsout.Therefore,thetherapistmustwatchthepatient’seyes todeterminewhenthebreakandrecoveryoccur.


NPCtestingisusedinbothchildrenandadultsinroutineeyecareexaminationsandduringvisionscreenings.Scheimanetal16investigatednormativedataforadultsanddeterminedclinicalcutoffval-ues.ReliabilityoftheNPCtesthasbeenestablishedwithelementaryschoolchildren.14ThiagarajanetalreportasignificantdifferenceofNPCbreakandrecoveryvalueswerefoundbetweenc/mTBIandnormalgroups.17(p460)

Interpretability

• Norms: Ina study involvingoptometricdiagnosing, Scheiman and colleagues16 suggestedthevalueof5cm(~2inches)fortheNPCbreakand7cm(~3–3.5inches)

fortheconvergencerecoveryinadultsus-inganaccommodativetargetorapenlightwithredandgreenglasses.

• MDC:notavailable • Responsivenessestimates:notapplicable


• Internalconsistency:notavailable • Interrater:Rouseandcolleaguesreportex-

cellentinterraterreliabilitywithchildren.14 • Intrarater: Rouseandcolleaguesreportex-

cellentwithin-sessionintraraterreliabilityoftheNPC,withICC0.94to0.98andgoodbetween-sessionreliability,withICC0.92to0.89.14Subjectswerechildren.

• Test-Retest:notavailable

Validity Estimates

• Content/Face:notavailable • Criterion:notavailable • Construct:notavailable

Selected References


ScheimanM,GallawayM,FrantzKA,etal.Nearpointofconvergence:testprocedure,targetselection,andnormativedata.Optom Vis Sci. Mar2003;80(3):214–225.

ThiagarajanP,CiuffredaKJ,LudlamDP.Vergencedysfunctioninmildtraumaticbraininjury(mTBI):areview.Oph-thalmic Physiol Opt. 2011;31:456–468.

BINOCULAR VISION: EYE ALIGNMENT TEST




• the patient hasmild-to-moderate braininjury or c/mTBI and observation offunctionalperformancesuggeststhepos-sibilityofvisualdysfunctioninanumberofdomains.

Thistestcanbeusedinconjunctionwithafullvi-sionscreentoscreenforaccommodationproblems.

Purpose/Description

Binocularvisionistheabilityofthevisualsystemtofuseorcombinetheinformationfromtherightandlefteyestoformoneimage.1Theimagesthatarrivefromeacheyemustbeidentical,andforthistooccur,botheyesmustbealignedsotheypointatthesameobjectatalltimes.Theterms“heterophoria”and“phoria”areusedtodescribeeyesthatturnin,out,orup.15Therearethreecommontypesofphoria:(1)exophoria(eyeshaveatendencytoturnout),(2)esophoria(eyeshavetendencytoturnin),and(3)hyperphoria(oneeyehasatendencytoturnup).1TheEyeAlignmentTestem-ploysthemethodsoftheModifiedThoringtonmethodandmaybeusedtoidentifyproblems,providetreat-ment,andmakereferrals.Itisnotintendedtoreplaceacomprehensivevisionevaluationbyanoptometrist.

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EXHIBIT 4-3

EYE ALIGNMENT TEST RESULTS

Horizontalalignment*:Verticalalignment†:Possibleimpairmentofeyealignment: Yes No*Asidentifiedbypatient,clinicalcutoffvalueoflessthan8forexophoria(leftofcenter),andlessthan4foresophoria(rightofcenter)†Asidentifiedbypatient,clinicalcutoffvalueoflessthan2


ThistestisonlyperformedoncewiththeMad-doxrodbeforetherighteye.Itisnotnecessarytorepeatthetest.Administrationtimeislessthan5minutes.As stated in several studies, includingGossetal,18thistestisquickandsimpletoperformandeasyforpatientstounderstand.

Equipment

AdultScreeningKit(GuldenOphthalmics,El-kinsPark,PA),whichincludeseyealignmentnearcard,Maddox rod,penlight, and theChronisterPocketAcuityCard.

Setup

Ifthepatienttypicallywearscorrectivelensesforreading,theyshouldbeusedforthistest.Positionthepatient tooptimize concentration,preferablysittingcomfortably.

Procedure

• Place thepenlight into theblackplasticholderbehindtheeyealignmentcard.

• Examiner shouldhold theMaddox rodhorizontallybeforetherighteye.

• Holdtheeyealignmentcard16inchesfromthepatient,perpendiculartotheface,withthelightateyelevel.

• Tell thepatient to look at the light andreportthroughwhichletterornumbertheredlineispassing.Ifthepatientisunabletoverballyrespond,askhim/hertopointtowheretheredlineispassing.

• Orient theMaddox rodverticallybeforetherighteye.

• Tell thepatient to look at the light andreportthroughwhichletterornumberthe

redlineispassing.Ifthepatientisunabletoverballyrespond,askhim/hertopointtowheretheredlineispassing.

Scoring

Record the letter or number reportedby thepatientforbothhorizontalandverticalalignment(Exhibit4-3).Comparethistothenormsprintedonthelowerright-handsideoftheeyealignmentcard.

Expected Findings

• Exophorialessthan8 • Esophorialessthan4

Possible Problems

• Thepatientonly sees the red lineor thewhitelight,butneverbothtogether.Thisindicatessuppression.

• Thepatient sees the red linemoving (itisunstable).Thisindicatesapossibleac-commodativeproblem(unstableaccom-modation).

• Thepatientreportsthattheredlineisnothorizontalorvertical(it isoblique).ThisindicatestheexaminerisnotholdingtheMaddoxrodhorizontallyorvertically.


This test has been studiedonhealthyyoungadults18–20andchildren.21Therearenopublisheddataonuseofthistestwithadultswithc/mTBI.

Interpretability

• Norms:notavailableforadults • MDC:notappropriate • Responsivenessestimates:notavailable

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• Internalconsistency:notappropriate • Interrater: Strong interrater correlation

foundwith themodified Thoringtonmethod(r=0.92).19

• Intrarater: Amongthesubjectivetests,themodifiedThorington testwas themostrepeatable.22However,nodifferencebe-tweentheresultsofthevarioustestswas“statisticallysignificant”forrepeatability.

• Test-Retest: notavailable

Validity Estimates

• Content/Face:notavailable • Criterion: Antona and colleagues com-

paredthemodifiedThoringtontestwiththreeothers(vonGraefetechnique,Mad-dox rod test, andprism cover test) andconcluded that due to the low level ofagreementobservedbetweenthesetests,interchangeabilityisnotrecommendedinclinicalpractice.22

• Construct: notavailable

Selected References

AntonaB,GonzalezE,BarrioA,BarraF,SanchezI,CebrianJL.Strabometryprecision:intra-examinerrepeatabilityandagreementinmeasuringthemagnitudeoftheangleoflatentbinocularoculardeviations(heterophoriasorlatentstrabismus).Binocul Vis Strabolog Q Simms Romano. 2011;26(2):91–104.

GossDA,MoyerBJ,TeskeMC.AComparisonofDissociatedPhoriaTestFindingswithVonGraefePhorometry&ModifiedThoringtonTesting.J Behav Optom. 2008;19(6):145–149.

LyonDW,GossDA,HornerD,DowneyJP,RaineyB.NormativedataformodifiedThoringtonphoriasandprismbarvergencesfromtheBenton-IUstudy.Optometry. Oct2005;76(10):593–599.

RaineyBB,SchroederTL,GossDA,GrosvenorTP.Inter-examinerrepeatabilityofheterophoriatests.Optom Vis Sci. Oct1998;75(10):719–726.

ScheimanM.Understanding and Managing Vision Deficits.Thorofare,NJ:SLACKIncorporated;1997.


SACCADES: DEVELOPMENTAL EYE MOVEMENT TEST

Purpose/Description

TheDevelopmentalEyeMovement(DEM)testis anumber-namingsaccadiceyemovement testthatwasoriginallydevelopedtoaddresssaccadicmovementsinchildren.Thereisaneedforasimilarassessmentinadults,assaccadiceyemovementsarealsoaconcerninadultswithacquiredbraininjuriessuchasstrokeorTBI,andonehasbeendeveloped.However,itisnotavailablepublicallyandtherearequestionswhethertheadulttestmaybeconsideredaparalleltesttotheDEMduetotheuseofdoubledigitnumberswhichmaymakeadifferenceintestperformance.23Duetothelackofsupportthatistrulyevidencebased, it is recommend touse theDEMusingtheage13norms,evenifthetestwillunder-identifyimpairmentinsaccadiceyemovements.24 Thepurposeof this test is toassess fixational

andsaccadeactivityduringreadingandnonread-ingtasks.Saccadecontrolistheabilityoftheeye

tomovefromonepointofinteresttoanotherafteranappropriateperiodof fixation.24These rapid,jumpingmovementsenablethesubject’simagetobeprojectedontothefoveaoftheeye,thesharp-estpointofvisualacuityhighlyconcentratedwithreceptorsandnervecells.Saccadicandfixationalactivityisimportantforwordrecognitionandforprocessinglargerunitsofprintedlanguage.24




• the patient hasmild-to-moderate braininjury or c/mTBI and observation of

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functionalperformancesuggeststhepos-sibilityofvisualdysfunctioninanumberofdomains.

Theverticalsubtestisusedtoevaluateautoma-ticityofnumber calling (language function) andevaluatechildrenatriskforreadingdisability(thisskillissignificantlycorrelatedwithreadingachieve-ment).25Thetestcanbeusedinconjunctionwithafullvisionscreentoscreenforaccommodativeandbinocularvisionproblems.


One of themain advantages of theDEM isthe easeof administrationwithout theneed forsophisticated instrumentation.Therefore, it is auseful instrument for patientswith decreasedattention and concentration.24 The oculomotorperformanceisassessedbyverbalnamingspeedandaccuracy.TheDEMiscomposedoftwoparts,thehorizontalandverticaltests.Bothtestsrequirerapid,continuousnaming.TheDEMconsistsof timingthepatientreading

aloud80double-digitnumbersarrangedverticallyand thesamenumbersarrangedhorizontally.Theverticaltestusestwotestplateswithtwocolumnsoneachpageand20evenlyspacednumbersineachcolumn.Thetestplateforthehorizontaltestiscom-prisedof16rowswithfiveunevenlyspacednumbersineachrow.Afteradjustingforerrors,thehorizontaltimeisdividedbytheverticaltime.Theresultingratioscoreisacomparisonofthespeedofreadingmaterialthatcomparesperformanceofanumber-namingtaskwithahighersaccadiceyemovementcomponent(ie,thehorizontaltestresults)toperformanceofthesamenumbernamingtaskwithalowersaccadiceyemovementrequirement(ie,theverticaltestresults).Thiscomparisonallowsforadjustmentfornumber-namingspeedandresultsinameasurementoftheefficiencyofhorizontal saccadic eyemovements.

Equipment

• DEMtest(consistsofthreesubtests) • VerticaltestA(contains40singledigits) • VerticaltestB(contains40singledigits) • HorizontaltestC(contains80singledigits) • Stopwatch

Setup and Procedure

• Thepatientviewsthetestcardsat40cm(~16inches)away

• AskthepatienttocalloutthenumbersonverticaltestsAandBasquicklyaspossiblefromtoptobottomwithoutusinghisorherfinger.

• Recordtimeanderrors(addition,omission,substitution).

• AskthepatienttocalloutthenumbersonthehorizontaltestCasquicklyaspossiblewithoutusinghisorherfinger.Thepatientcallsoutthenumbersacrossthepage.

• Recordtimeanderrors(addition[A],omis-sion[O],substitution).

• Calculatethescoretodeterminewhetherornottoreferthepatienttoavisionspecialist.

Scoring

• Vequalsthetotalcompletiontimeforverti-caltestsAandB(inseconds).

• Determine thehorizontal adjusted (HA)responsetimeasfollows(wherehorizontaltime[HT]isinseconds):HT ×80/(80–O +A).

• Determine the ratio score by dividingtheHA timebytheverticaltime(ratio=HA/V).

• Comparetheservicemember’sscoretothereferralcutpointbasedontheage13norm(Exhibit4-4).Referaccordingly.


TheDEMwasinitiallynormedandadministeredto556elementaryschoolstudentsranginginagefrom6-13years.25Theauthorswereunawareofanysample selectionbiases.25 Tassinari andDeLandaddresseditsreliabilityandassociatedsymptom-atology.25Thisinstrumenthasnotbeentestedonadultswithc/mTBI.

Interpretability

• Norms:determinedbyusingthenormsforage13byGarciaetal25 (seeExhibit4-4).Servicememberswhose ratio scores areone standarddeviationabove themean(eg,abovethecutpoint)shouldbereferredtoavisionspecialist.



• Internalconsistency: Garciaetalfoundthatthecorrelationsbetweenallsubtestswere

112


reliability for vertical, horizontal, andratio.26

Validity Estimates

• Content/Face:notavailable • Criterion:notavailable • Construct: TheWideRangeAchieve-

mentTestwascomparedtotheDEM.Theresultsindicatedmoderatetohighnegative correlations with all DEMsubteststhatweresignificantattheP<0.001level(verticaltimer=–0.79;horizontaltimer=–0.78;ratio=–0.55).25

significant(P<0.001)exceptverticaltimeandratioscore(r=–0.05)25

• Interrater:Testingtheinterraterreliabilityfoundvertical time, r= 0.81,horizontaltime,r=0.91,ratior=0.57(P<0.01).25

• Intrarater:Testingtheintraraterreliabilityfoundvertical time, r= 0.89,horizontaltime,r=0.86,ratior=0.57(P<0.01).25

• Test-Retest:Thereareseveralstudiesthataddress this in childrenwith varyingresults.Verticaltime,r=0.85;horizontaltime, r=1.89; ratio scores (corrected forattenuation),r=0.66.25Therearetworeli-ability studies that showpoor test-retest

EXHIBIT 4-4

DEVELOPMENTAL EYE MOVEMENT TEST RESULTS

TestAVertical:secondsTestBVertical:secondsAdjustedVerticalTime(V) = (testsA+B)=secondsTestC–Horizontal(HT):secondsErrors:additions(A)omissions(O)substitutionstranspositionHorizontalAdjustedTime(HA)=HT ×80/(80–O+A)=Ratioscore:HA / V = Comparescoretocutpointbelow*:Possibleimpairmentofsaccades: Yes No*Clinicalcutoffvalueisaratioscoregreaterthan1.22.Cutoffforscreeningisdeterminedas1standarddeviationabovethemeannormforage13(ratiomean=1.12,standarddeviation=0.10[noadultnormsavailable]).Datasource:RichmanJE.DEM Manual: The Developmental Eye Movement Test: Examiner’s Manual.Version2.0.Mishawaka,IN:BernellCorporation;2009.

Selected References

GarciaRP,RichmanJE,NicholsonSB,GainesCS.Anewvisual-verbalsaccadetest:TheDevelopmentalEyeMove-menttest(DEM).J Behavioral Optom.1990;61:124-135.

PowellJM,BirkK,CummingsEH,ColMA.TheneedforadultnormsontheDevelopmentalEyeMovementtest.J Behavioral Optom. 2005;16(2):38–41.

Tassinari JT,DeLandP.Developmental EyeMovement test: reliability and symptomatology.Optometry. Jul2005;76(7):387–399.

PURSUITS AND SACCADES: NORTHEASTERN STATE UNIVERSITY COLLEGE OF OPTOMETRY OCULOMOTOR TEST

Purpose/Description

TheNortheastern StateUniversityCollegeofOptometry (NSUCO)OculomotorTestisadirectobservationaltestforscreeningsaccadesandpur-suitstodetermineifapatientdemonstratesimpair-mentwiththesevisualskills.Saccadesarequickeyemovementsthatoccurwhentheeyesfixonvarious

targetsinthevisualfield,27andpursuitsare“eyemovementsthatmaintaincontinuedfixationonamovingtarget.”27(p241) Thepurposeofthisstandardizedtestistoassess

fouraspectsofpursuitsandsaccades,including:(1)ability(sustainingpower),(2)accuracy,(3)degreeofheadmovementthepatientusestoperformthetask,and(4)degreeofbodymovement.Itmaybe

113


usedtoidentifyproblems,providetreatment,andmakereferrals;itisnotintendedtoreplaceacom-prehensivevisionevaluationbyanoptometrist/ophthalmologist.



1. thepatienthasnothadacomprehensivevisual assessment by an optometrist/ophthalmologisttoidentifyvisualimpair-ments,and

2. thepatienthasmild-to-moderatebraininjury or c/mTBI and observation offunctionalperformancesuggeststhepos-sibilityofvisualdysfunctioninanumberofdomains.

Thistestcanbeusedinconjunctionwithafullvisionscreentoassesssaccadesandpursuitsandcanbeusedforpatientsages5toadulthood.


Required equipment includes two small (ap-proximately a 1/2-inch diameter), colored, re-flectivespheres (balls)mountedondowelsticks.Administration time is less than5minutes.Thelimitedverbalinteractionrequiredbytheexaminertogetherwithobjectiveobservationsenablesthistobeanadvantageousdirectobservationaltest.


AlthoughtheNSUCOOculomotorTestiswidelyusedwithadultpatients,ithasnotbeenformallytestedonadultswithorwithoutbraininjury.Ithasbeentestedextensivelyonchildrenuptotheage

of14,includinginterraterandintraraterreliability,and test-retest reliability,28 construct validity,29,30 andnorms.31

Interpretability

Thistesthasnotbeennormedonadults.Becauseoculomotordevelopmentisbelievedtoplateaubyage14, cliniciansmayconsiderusing thenormsreportedby Maples,Atchley, andFicklin (Tables4-2and4-3).Todoso,theclinicianassignsascoreof1through5basedonthescoringcriteria,thencompareseachscoretothefailurecriteria.Scoresthat fall below theminimal levelsmay indicateimpairment.Beyondassigning scores, therapistsmayusetheNSUCOOculomotorTestasavenueforobservingpatientperformanceinareasofabil-ity,accuracy,andheadandbodymovementandusetheseobservationstodecidewhethertoreferthepatienttoavisionspecialistformorein-depthevaluation.

• MDC: notavailable;however,repeattest-ingovertimewithchangesinperformancewouldgivedifferentscores.

• Responsivenessestimates:notavailable


• Internalconsistency:notavailable • Interrater: 21elementary students tested

with24studentcliniciansscoring: ° Average exact agreement of the four

scoresofthepursuitstest:73.5%.28 ° Average exact agreement of the four

scoresofthesaccadestest:75%.28 • Intrarater: 21elementarystudents tested

with24studentcliniciansscoring: ° Average exact agreement of the four

scoresofthepursuitstest:90%.28

TABLE 4-2

SACCADES: NORMS FOR INDIVIDUALS 14 YEARS OF AGE AND OLDER*

SACCADES

Ability Accuracy Head Movement Body Movement

Male Lessthan5 Lessthan4 Lessthan3 Lessthan5Female Lessthan5 Lessthan3 Lessthan4 Lessthan5

*Scoresindicatefailure.Adaptedwithpermissionfrom:MaplesWC,AtchleyJ,FicklinT.NortheasternStateUniversityCollegeofOptometry’soculomotornorms. J Behav Optom.1992;3:149.

114


° Average exact agreement of the fourscoresofthesaccadestest:83%.28

• Test-Retest:21elementarystudentstestedwith twopaired scores on each scale (8observations×21patients=168possiblesignificantdifferences).87%reliabilitywith22significantdifferencesfoundatthe.05level.31

Thistestdidnotshowsignificantimprovementonretestexceptforimprovementinsaccadeheadmovement.31

Validity Estimates

• Content/Face:notavailable • Criterion:notavailable • Construct:NSUCOOculomotorTestwas

usedtocompareacademicperformanceinnormal, learning-disabled,andgifted

children.Thedifference betweengiftedand learning-disabled childrenwas sta-tistically significant in two tests out ofeight; however, three tests approachedsignificance.Giftedandnormalchildrenwere found to be very similar.29,31 TheNSUCOOculomotorTestwasalsousedtocomparegoodreadersandpoorreadersin a thirdgrade class asdeterminedbytheGatesMcGinitieorScienceResearchAssociationAchievementReadingTestAchievementReadingTest.Videotapesweremadeof the oculomotor behaviorof bothgood readers (average 1 year, 9monthsabovegradeplacement)andpoorreaders(average1year,3monthsbelowgrade placement).All eight categoriesforpursuitsandsaccadestestedatasig-nificantlydifferentperformanceatthe0.5levelorbetter.30,31

TABLE 4-3

PURSUITS: NORMS FOR INDIVIDUALS 14 YEARS OF AGE AND OLDER*

PURSUITS

Ability Accuracy Head Movement Body Movement

Male Lessthan5 Lessthan5 Lessthan4 Lessthan5Female Lessthan5 Lessthan4 Lessthan4 Lessthan5

*Scoresindicatefailure.Adaptedwithpermissionfrom:MaplesWC,AtchleyJ,FicklinT.NortheasternStateUniversityCollegeofOptometry’soculomotornorms. J Behav Optom.1992;3:149.

Selected References

MaplesWC,AtchleyJ,FicklinTW.NortheasternStateUniversityCollegeofOptometry’soculomotornorms.J Behav Optom. 1992;3:143–150.

MaplesWC,FicklinTW.Inter-raterandtest-raterreliabilityofpursuitsandsaccades.J Am Optom Assoc. 1988;59:549-552.

QuintanaLA.AssessingAbilitiesandCapacities:Vision,VisualPerceptionandPraxis.In:RadomskMV,TromblyLathamCA,eds.Occupational Therapy for Physical Dysfunction.Philadelphia,PA:Lippincott,Williams&Wilkins;2008:234–259.

Standard Setup

• Posture:positionpatient standing,withfeetshoulder-widthapart,directlyinfrontoftheexaminer.

• Head:noinstructionsaregiventothepa-

tienttomoveornottomovehisorherhead. • Targetcharacteristics:small(approximate-

ly1/2-inchdiameter), colored, reflectivespheres(balls)mountedondowelsticks.One target isused forpursuits, two forsaccades.

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Movement of the Target

Directional

• Saccadesareperformedinthehorizontalmeridianonly.

• Pursuitsareperformedrotationally,bothclockwiseandcounterclockwise.

Extent

• Saccadeextentshouldbeatapproximately4inchesoneachsideofthepatient’smid-line(8inchestotal).

• Pursuitpath shouldbe approximately 8inchesindiameter.Theupperandlowerextentofthecircularpathshouldcoincidewiththepatient’smidline.

• Testdistance from thepatient: nomorethan15.5inchesandnolessthantheHar-mondistance(thedistancefromthesub-ject’smiddleknuckletohisorherelbow).

• Ocularcondition:binocularonly • Ageofthepatient:5yearstoadult31

Instructions

• Saccades:“WhenIsay‘red,’lookattheredball.WhenIsay‘green,’lookatthegreenball.Remember,don’tlookuntilItellyouto.”

• Pursuits:“Watchtheballasitgoesaround.Trytoseeyourselfintheball.Don’tevertakeyoureyesofftheball.”31

Scoring

• Ability: can thepatientkeephis orherattentionunder control to complete fiveroundtripsforsaccadesandtwoclockwiseandthentwocounterclockwiserotationsforpursuits?

° Saccades 1. Completes less than two round

trips 2. Completestworoundtrips 3. Completesthreeroundtrips 4. Completesfourroundtrips 5. Completesfiveroundtrips ° Pursuits 1. Cannotcomplete1/2rotationsin

either the clockwise or counter-clockwisedirection

2. Completes 1/2 rotation in eitherdirection

3. Completes one rotation in eitherdirection

4. Completestworotationsinonedi-rectionbutlessthantworotationsintheotherdirection

5. Completes two rotations in eachdirection

• Accuracy (pursuits and saccades are graded alike):canthepatientaccuratelyandconsistentlyfixatesononoticeablecor-rectionisneededinthecaseofsaccades,ortrackthetargetsononoticeablerefixationisneededwhendoingpursuits?

° Saccades 1. Large over- or undershooting is

notedoneormoretimes. 2. Moderateover-orundershooting

isnotedoneormoretimes. 3. Constant slight over- or under-

shootingisnoted(greaterthan50%ofthetime).

4. Intermittentslightover-orunder-shootingisnoted(lessthan50%ofthetime).

5. No over- or under-shooting isnoted.

° Pursuits 1. Noattempttofollowthetarget,or

requiresgreaterthan10refixations 2. Refixations5–10times 3. Refixations3–5times 4. Refixations2timesorless 5. Norefixations • Head and body movement:canthepatient

accomplish the saccade or pursuit testwithoutmovinghisorherheadorbody?Bothsaccadeandpursuitscoringusethesamecriteriaforthisaspectofthetesting.

1. Largemovement of the head orbodyatanytime

2. Moderatemovementof theheadorbodyatanytime

3. Slightmovement of the head orbodygreaterthan50%ofthetime

4. Slightmovement of the head orbodylessthan50%ofthetime

5. Nomovementoftheheadorbody

Recordresultsandcomparetonorms(Exhibit4-5,seeTables4-2and4-3).31

116


CONFRONTATION FIELD TEST


Kerretal32investigatedtheaccuracyofconfron-tationvisualfieldtestingwithadultsubjectswithvisualdeficitetiologiesincluding:glaucoma,opticneuropathies, opticneuritis, glioma, stroke, andchiasmal tumors.Trobeet al33 comparedvariousfingerandcolorconfrontationtestsinidentifyingchiasmalandopticnervevisualfielddefects.Sub-jectsincludedpersonswithchiasmalhemianopiasandneuropathy-relatednerve-fiber-bundledefects.Agewasnot specified. Shahinfar, Johnson, andMadsen34 reported specificity onvariousvisualfielddefects,includinghemianopias.Thistesthasnotbeenvalidatedonadultswithc/mTBI.

Interpretability

Kerretal32 investigatedtheaccuracyofcon-frontation visual field testing and concludedthatwhenperformedindividually,confrontation visual field tests are insensitive at detectingvisualfieldloss.Whenconfrontationtestswerecombined, sensitivity improved. Finger count-ingcombinedwithstaticfingerwiggleachieved44.6%sensitivityand97.2%specificity.Useofakineticredtargetresultedinthehighestsensitiv-ityandspecificity.

• Norms:therearenonormsforthistestandtotalscoreisnotcalculated.

° InPart1,thepatientshouldbeabletoseethetargetatapproximatelythesamepointatwhichyoucansee it. If thereappearstobeasignificantdiscrepancy,

Purpose/Description

Visualfielddeficitisavisualconcernassociatedwith acquiredbrain injury.15Confrontation fieldtesting enables the therapist to screen for grossperipheralvisualfieldloss.


Thereareseveralconfrontationfieldtestsandthechoiceoftestsmayaffectthelikelihoodofidentify-ingavisual fielddefect.32Theconfrontation fieldtestshouldbeusedasascreenonlybecauseitlacksadequate sensitivity33; therefore, if the screeningresultsarenegativebutthepatient’sbehaviorsug-gestsfieldloss,heorsheshouldstillbereferredtoavisionspecialist.15Thistestmaybeahelpfulinclusioninaninitialoccupationaltherapyevaluationwhen:


• the patient hasmild-to-moderate braininjuryorcomplicatedc/mTBIandobser-vationoffunctionalperformancesuggeststhepossibilityofvisualdysfunctionalinanumberofdomains.


Requiredequipmentincludestwoeyepatches/occludersandatargetwhitesphere,3mmorlessindiameter,mountedonanonglossywand.Ad-ministrationtimeislessthan5minutes.

EXHIBIT 4-5

PURSUITS AND SACCADES: NORTHEASTERN STATE COLLEGE OF OPTOMETRY EYE MOVEMENT TEST

Pursuits Saccades

Ability

Accuracy

HeadMovement

BodyMovement

Datasource:MaplesWC,AtchleyJ,FicklinTW.NortheasternStateUniversityCollegeofOptometry’soculomotornorms.J Behav Optom. 1992;3:143–150.

117


avisualfielddeficitmaybepresentandareferralisnecessaryforamoreprecisemeasurementofthepatient’svisualfield.

° InPart2,youaretestingthepatient’sabilitytoseetwoobjectssimultaneously.PatientswithvisualneglectwillhaveproblemswiththetaskeveniftheydowellwithPart1.


Reliability Estimates:notavailable

Validity Estimates

• Contentvalidity:notavailable • Criterion validity: Kerr et al32 found

confrontation testing tobe insensitive todetectingvisualfieldlossascomparedtoautomatedperimetry.

• Constructvalidity:notavailable

Selected References

KerrNM,ChewSS,EadyEK,GambleGD,Danesh-MeyerHV.Diagnosticaccuracyofconfrontationvisualfieldtests.Neurology. 2010;74(15):1184–1190.

ShahinfarS, JohnsonLN,MadsenRW.Confrontationvisual field lossasa functionofdecibel sensitivity lossonautomatedstaticperimetry.Implicationsontheaccuracyofconfrontationvisualfieldtesting.Ophthalmology. Jun1995;102(6):872–877.

TrobeJD,AcostaPC,KrischerJP,TrickGL.Confrontationvisualfieldtechniquesinthedetectionofanteriorvisualpathwaylesions.Ann Neurol. 1980;10:28–34.


Part 1

Preparation 1. Patch thepatient’s left eye; patchyour

righteye. 2. Sitapproximately20inchesoppositethe

patient;your lefteyeshouldbedirectlyoppositethepatient’srighteye.Optimally,thereshouldbeadark,uniformwallbe-hindthepatient.

3. Provideinstructionstothepatient.Tellthepatientthatyouwillshowvariousfinger counts with your hand fromtheside.Askthepatienttoreportassoonasheorsheseesyourhandandhowmany fingers you are holdingup,whilecontinuingtolookdirectlyatyourlefteye.

Testing 1. Startatthe12-o’clockpositionandslowly

moveyourhand(3-fingercount)untilthepatient first reports seeing it (theobjectshould be placed evenly between thetherapistandthepatient).

2. Comparethepatient’sresponsetoyours.Ifthepatientcannotseethetargetassoonasyoucan,itisanindicationofapossibleproblem.

3. Moveclockwise to the2-,4-,6-,8-,and10-o’clockpositions and repeat proce-dures1and2.

4. Recordapproximatelywherethepatientreportsseeingthetargetineachorienta-tiontested.

5. Patchthepatient’srighteye;patchyourlefteye.

6. Sit opposite thepatient.Your right eyeshouldbedirectlyoppositethepatient’slefteye.

7. RepeatthetestingproceduredescribedinSteps1-4.

8. Recordresults(Exhibit4-6).

Part 2

Preparation 1. Patch thepatient’s left eye; patchyour

righteye. 2. Sitapproximately20inchesoppositethe

patient;your lefteyeshouldbedirectlyoppositethepatient’srighteye.Optimally,thereshouldbeadark,uniformwallbe-hindthepatient.

Testing 1. Extendyourarms soyourhandsare in

the3-and9-o’clockpositions.Yourfingersshouldbepositionedsothatyoucanseethem fromyour open eye. Instruct the

118


STEREO RANDOT TEST

patienttotellyouhowmanyfingersyouareholdingupwitheachhand.

2. Patchthepatient’srighteye;patchyourlefteye.

3. RepeatStep1. 4. Recordresults(seeExhibit4-6).

Confrontation Field Test Results

• InTestingPart 1 thepatient shouldbeable to see the target at approximately

EXHIBIT 4-6

CONFRONTATION FIELD TEST RESULTS

Part 1

Position Right Eye Left Eye

Doesthepatientsee Ifno,#ofapproximate Doesthepatientsee Ifno,#ofapproximate thetargetwhen degreesfromcenter, thetargetwhen degreesfromcenter, expected?(Y/N) patientseestheobject expected?(Y/N) patientseestheobject

12

2

4

6

8

10

Part 2

Right Eye Left Eye

Doesthepatientseethecorrect#offingers?(Y/N) Doesthepatientseethecorrect#offingers?(Y/N)

thesamepointatwhichyoucanseeit.Ifthereappearstobeasignificantdiscrep-ancy,avisualfielddeficitmaybepresentandareferralisnecessaryforamorepre-cisemeasurementofthepatient’svisualfield.

• InTestingPart2,youare testingthepa-tient’sabilitytoseetwoobjectssimultane-ously.PatientswithvisualneglectwillhaveproblemswiththetaskeveniftheydowellwithtestingPart1.

Purpose/Description

TheStereoRandotTestisusedtoscreenforstereopsis(binocularvision).Thistestrequiresthepatienttoidentifyforms(geometricformsoranimals) fromrandomdotbackgroundswhilewearingpolarized3-Dviewingglasses.Itmaybe used to identify problems, provide treat-ment,andmakereferrals; it isnotintendedtoreplace a comprehensive vision evaluation byanoptometrist.




• the patient hasmild-to-moderate braininjury or c/mTBI and observation of

119


EXHIBIT 4-7

STEREO RANDOT TEST RESULTS

Abletoidentifyallformscorrectly? Yes No

#Correct:/6

functionalperformancesuggeststhepos-sibilityofvisualdysfunctioninanumberofdomains.

Thistestcanbeusedinconjunctionwithafullvisionscreentoassessforstereopsis.


Equipment needs include the StereoRandotTest kit (available throughBernellVTP. www.stereooptical.com/products/stereotests#randot).Administrationtimeislessthan2minutes.

Groups Tested With This Measure: notavailable

Interpretability

• Norms:normal stereo is expected in alladults.Thepatientshouldbeabletoiden-tifyallofthesimpleformscorrectly.Apa-tientwhohasaconstantstrabismuswillbeunabletoidentifyanyoftheforms.Patientswithlesssevereproblems,suchasintermit-tentstrabismusandheterophoria,willgen-erallyhaveanormalresponse.Itispossibleforapatientwithacquiredbraininjurytoreportdoublevisionon this task,whichwouldsuggestthatastrabismusispresent.

• MDC: notapplicable,noexpectedchangeinperformance

• Responsivenessestimates:notapplicable

Reliability and Validity Estimates: notavailableforadults

Setup

Thepatientmustbeabletopositionhisorherheadvertically(withouttilting)tocorrectlyperformthistest.Ifnot,donotusethistest.


Cliniciansareadvisedtofollowtheadministra-tionprotocol specified in theStereoRandotTestkit’s InstructionManual. In general, this test isadministeredasfollows.

1. Askthepatienttoputonthe3-Dviewingglasses(overprescriptionlenses,ifneedbe).HoldtheTestupright16inchesfromthepatient’seyes.Askwhatthepatientsees.Ifthepatienthasstereopsis,heorshewillreportseeinggeometricforms(depending upon the version of thetestselectedbytheclinician).Givethepatient20to30secondstotrytoseethetargets.

2. Ifthepatienthasdifficulty,makesuretheheadisnottiltedtotheside.

3. Itishelpfultohaveadrawingavailableofthetestforms(locatedonthefrontofthe instructionmanual). If the patientstruggleswith the task, you can showthepossibleforms.Ofcourse,itismoreconvincing if thepatient,withoutpriorknowledgeoftheforms,isabletoidentifyallcorrectly(Exhibit4-7).

Expected Results

Normalperformance:Thepatientshouldbeabletoidentifyformscorrectly;however,itshouldbenotedthatpatientswithlesssevereproblems,suchasintermittentstrabismusandheterophoria,willgenerallyhaveanormalresponse.Abnormalperformance: Thosewith constant

strabismuswill beunable to identify anyof theforms. It ispossible for apatientwith acquiredbrain injury toreportdoublevisionon this task,suggestingpossiblestrabismus.

BRAIN INJURY VISUAL ASSESSMENT BATTERY FOR ADULTS

Purpose/Description

The BrainInjuryVisualAssessmentBatteryforAdults(biVABA) isabatteryoftestsusedtoscreenvisualprocessing followingbrain injury.Resultsenabletherapiststomakeappropriatereferralsandaddressfunctionallimitations.35ThebiVABAisnotintendedtoreplaceacomprehensivevisionevalu-ationbyanoptometrist/ophthalmologist.

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manceandtypesofsearchpatternsofthesubtestsin81participants.37

Interpretability

Themanualprovides result interpretation, in-cludingdescriptionsofnormaltestingreactions.Forexample,foracuity,1Mprintisstandard-sizedprint(newspaper);forpupillaryresponses,thenormalpupilshapeisdescribedandanapproximatesizeforpupilsinawell-illuminatedroomisgiven.Seemanualforinterpretationsofpatientresponses.

• Norms:Analysisofnormsofdescriptivesearchstrategiesandcut-offpercentilesaregivenforthesevensubtestsofthevisualscanningsection(seefulldetaileddiscus-sioninproductmanual).


Reliability and Validity Estimates

MostofthesubteststhatcomprisethebiVABAhavepreviouslybeenevaluatedforreliabilityandvalidity.36

• ThebiVABAincludesthreestandardvisualscreeningteststhatareacceptedbyoph-thalmologistsasvalidandreliableassess-menttools(theLeaNumbersIntermediateAcuitytest,theLeaLowContrastAcuitytest,andtheDamatoCampimeter).

• TheWarrentextcardisamodificationoftheLighthouseNearVisionReadingCard.

• Thescreeningforoculomotorperformanceis composedof standard screening teststhat are routinelyusedbyophthalmolo-gistsandneurologists.

• Thedesigncopytestisadaptedfromtheliterature.

• Thevisualsearchsubtestsuseacancella-tiontestformatthathasbeenstudiedandusedextensivelyinresearchandhasverygoodvalidityestablishedbyresearch.




• thepatienthasmild-to-moderatebrainin-juryorcomplicatedconcussion/mTBIandobservationoffunctionalperformancesug-geststhepossibilityofvisualdysfunction.

ThebiVABAisalsoappropriateforanyonewhohasexperiencedabraininjuryfromanycause,in-cludingcerebrovascularaccident,TBI,braintumor,anoxia,oranyonewhohasexperiencedtraumatotheeye.35ThebiVABAcanbeusedforpatientsages14yearsandabovewithoutmodification.


ThebiVABAiscomprisedofabatteryofsubteststhat includesa clinicalobservationchecklistandassessmentsofvisualacuity(distanceandreading),contrast sensitivity function, visual field, oculo-motor function, visual attention, and scanning.Administrationtakesapproximately60minutes.Detailedadministrationandscoringprocedures

areavailableforpurchasefromthedeveloper(vis-ABILITIIESRehabServices,Inc;www.visabilities.com)andarenot included in thisToolkit. Clini-cians should refer to the biVABA’s test bookletandmanualforadditionalinformationregardingpsychometricpropertiesandscoreinterpretation.


ThebiVABAhasnotbeentestedonadultswithTBI,andonlythevisualsearchsectionofthebiVA-BAhasbeenempiricallytested.Thesevensubtestsusedtoassessvisualsearchhavebeenincludedintwostudies:theywerefieldtestedon25subjectsbetweenages16and83todetermineusualsearchpatternsandnorms35,36andtodescribetheperfor-

SECTION 2: VISUAL INTERVENTIONS

INTRODUCTION

Vision is themost far-reachingofour sensorysystems.Changestothissystemcanaffectpatients’abilitytoparticipateintherapyaswellasfunctionin

everydaylife.15Brahmandcolleagues2suggestthatcombattroopswithblast-relatedc/mTBIareatriskforvisualdysfunction.Occupational therapistsare

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standing,orperformingataskthatinvolveswalking.

Compensatory Approaches to Visual Deficit

• Modifythetaskortheenvironmenttomax-imize thepatient’s ability toparticipate.

• Educatethepatientabouttheimpairment. • Teachandpracticemethodstocompensate

forthedeficit.

Grading the Tasks, Activity Analysis

• Density:lowdensitytohighdensity(eg,startwithtwocolumnsofletters,oneoneachsideofthepage,thenprogressto10columnsofletters;Figure4-2)

• Structure: task (ie, startwith organizedsimplestructureandmove towardsran-dom;Figure4-3)

• Speed: startwith slow,deliberatemove-ment;slowlyincreasespeed(useametro-nome,ifdesired)

Other Suggestions for Oculomotor Therapy

• Enablethepatienttoachieveearlysuccess. • Emphasizeaccuracythenworkonspeed

(saccadicandpursuitactivities). • Forsaccadesactivities,workfromlargeto

smalleyemovements. • Forpursuitsactivities,progressfromsmall

tolargeeyemovements. • Workoneyesindividuallyuntileyesare

equalinability,thenworkoneyestogether. • Eliminateheadmovementsduringpursuit

andsaccadiceyemovementsforactivitiesthat canbe accomplishedwithoutheadmovement.

• Increasethecomplexityofthetaskstoworktowardautomaticeyemovements.Optionsinclude adding ametronome, balanceboard,orcognitivetaskthatincorporateseyemovements.

oftenthefirst-lineclinicianswhoareabletoidentifypossiblevisualimpairment.Theoccupationalthera-pist’srolesincludeevaluatingvisionfunctionthroughvisionscreeningand functionalobservationsanddeterminingwhetherandhowvisual impairmentmaybeaffectingthepatient’sfunctionalperformance.Ifvisual impairmentissuspected,theoccupa-

tionaltherapistisresponsiblefor:

• referringthepatienttoastaffoptometristwithexpertiseinvisionandTBIforfurtherevaluationandinterventionmanagement,

• educatingthepatientandtherehabilitationteamabouthowtheimpairmentisaffect-ingthepatientfunctionally,

• providingcompensatorytreatment, • providingremedialtherapyunderthesu-

pervisionofanoptometristwithexpertiseinvisionandTBI,and

• providingvariousactivities thatwillad-dressvisual impairmentswhileworkingonotherimpairments.

General Instructions for Treating Visual Impairments

Alwaysmakesurethepatienthasthebestcor-rectedvision (ie,wearing thecorrectglasses) forparticipatingintherapyandthatthecorrectionfitswell (seeGeneral Instructions forVisionAssess-mentforinstructionsonbestfitanduseofbifocalsandtrifocals).Decidewhatkindofenvironmentisbestfortheimpairmentandfocusofthetreatment(determinedbythepatient’s levelof impairmentanddistractibility).Theenvironmentshouldbe:

• welllitwithnoglare; • clutter-free,unlessthepatientisworking

onmorecomplexvisualtasks;and • quiet, unless thepatient isworking on

morecomplextasks.

Determinewhetherthepatientshouldbeseated,

Selected References

BrahmKD,WilgenburgHM,Kirby J, IngallaS,ChangCY,GoodrichGL.Visual impairmentanddysfunction incombat-injuredservicememberswithtraumaticbraininjury.Optom Vis Sci. Jul2009;86(7):817–825.


WarrenM.Ahierarchalmodelforevaluationandtreatmentofvisualperceptiondysfunctioninadultacquiredbraininjury,PartII.Am J Occup Ther. 1993;47:55–66.

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Figure 4-2.Examplesofhigh-density(a) andlow-density(b) visualstimuli.

Other Resources for Occupational Therapy and Vision


ZoltanB.Vision, Perception, and Cognition: A Manual for the Evaluation and Treatment of the Adult With Acquired Brain Injury.4thed.Thorofare,NJ:SLACKIncorporated;2007.

a b

Figure 4-3. Examplesofstructured(a)andunstructured(b)visualstimuli.

a b

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POOR ACUITY

follow are included in textbooks and literaturerelatedtolowvision.

Interventions

• Referthepatienttoaneyespecialist(op-tometristorophthalmologist).Thepatientneedstobeevaluatedforappropriatepre-scriptiontomaximizevisionclarity.

• Ifthepatienthassignificantacuityimpair-ment,heorshemayneedtobereferredtoalow-visionspecialist.

• Educatethepatientonproperuseofglassesandaboutimpairment.

• Teachthepatientcompensatorystrategies,suchas

° increasingillumination, ° increasingcontrast, ° increasing size (enlargement or

magnification), ° decreasing background pattern or

clutter,and ° organizingtheenvironment. • Providesensorysubstitutionusingassis-

tivedevices.

Purpose/Background

Acuityreferstoclarityofvisionandtheabilitytoseedetail.Whenacuityisaffected,apatientmayhavedifficultyreading,doingfinemotortasksthatinvolvehand-eyecoordination,recognizingfaces,and the like. Impairedacuitymaybe connectedtoreducedcentralvisionandvisualfieldloss.Forsomepatients,treatmentmaybeassimpleaswear-ingglasses correctlyor referral toaneyedoctor,otherpatientsmayhavesomedamagetotheeyeoreyesystemthatmaylimittheamountofcorrectedprescriptionoptions available tomakeapatientfunctionalagain.Visual impairment is acuity less than 20/60

(normal being 20/20).36 The legal definition ofblindness in theUnitedStates isvisualacuityof20/200orworse(orseverelyrestrictedperipheralvision).Blindnessisdefinedasvisualacuityworsethan20/400.39

Strength of Recommendation: Practice Option

Althoughtherearenoformalstudiesthatindicate whichinterventionsarebest,theinterventionsthat

Selected References

Answers.com.VisuallyImpairedwebpage.http://www.answers.com/topic/visually-impaired.AccessedJune17,2013.



WarrenM.Evaluationandtreatmentofvisualdeficits.In:PedrettiLW,EarlyMB,eds.Occupational Therapy: Practice Skills for Physical Dysfunction.5thed.StLouis,MO:Mosby;2001:386–421.

Education

Encourage Proper Use of Glasses

• Patient shouldwear the appropriateglassesforthetask(eg,distance,reading,andcomputerdistanceglasses).

• Besurethepatient’sglassesfitcorrectly. • Be sure thepatientuses theappropriate

portionand focaldistance (workingdis-tance)fortheglasses.Somepeoplewearprogressive lenses,whichwill nothaveobvioussegments,butplacementshouldbesimilar(seeFigure4-1).

° Upperportionisfordistance

° Trifocalformid-distance(18–24inches;eg,computermonitor)

° Neardistance • Somepeoplenowwearmonovisioncon-

tactsinwhichoneeyeisusedfordistanceandtheotherfornearvision.Thiswillaf-fecthowpatientsusetheireyesandhowtoapproachtreatment.

Compensatory Techniques and Teaching

Thefollowingarecompensatorytechniquesthatcanbeusedintheclinicforapatientwithpoorvi-sualacuityaswellastoteachthepatienttobetterfunctionoutsidetheclinic.

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Figure 4-4. Task lamp shouldbeplacedbelow thepatient’sglassesanddirectedontothetable,readingmaterial,ortask.

Figure 4-5.Increasecontrastforfoodpreparationsandputbrighttapeortexturedstickersondials.

Figure 4-6.Addthick,darklinestochecksandotherforms.

Increase Illumination

• Increasetheamountoflight. • Determinethebestlightingoptionforthe

patientthatalsominimizesglare(eg,incan-descentbulbs,halogen,fluorescent[mayhaveflickereffect],andfullspectrum).

• Ifpossible,placethelightbelowpatient’sglassesoropticaldevicetopreventglareofftheglass(Figure4-4).

• Sometimestasklampsarebetterthanroomlights.

Increase Contrast

Increase contrast by, for example, placingblack coffee in awhitemug, butter on adarkplate, contrasting colored tape on the edge ofsteps,coloredsoaponawhitesink(Figures4-5,4-6,and4-7).

Decrease Background Pattern

• Usesolidcolorsfortableclothorbedspreadtomoreeasilyfinditemssetontopofit.

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Figure 4-7.Addcontrastingcoloredstripestoedgesofstairs.

• Useplaindishesandsolid-coloredplace-mats.

• Simplifyjunkdrawers.

Decrease Clutter and Organize Environment

• Putitemsaway. • Organizestorageplaces.

Increase Size

• Enlargeprint. • Usethickmarkers(seeFigure4-6). • Enlargecomputerfont.

Magnify

• Usehandhelddevicesanddeterminethebestfocaldistanceofthedevice(thedis-tanceofthelensfromtheobjectorreadingmaterialwiththebestclarity;thelightraysconverge).

• Teachpatientmethods tomaintain thedistance.

• Usehandor finger to stabilize thehandhelddevice

• Use handheld stand magnifier that

maintainsdistance(goodforpatientswithincoordinationandataxia).

Use Visual Markers

• Forreading,usearulerunderthelinebeingread.

• Fordialsonappliances,putbrighttapeortextured stickerson themost commonlyusedsettings(seeFigure4-5).

IMPAIRED PURSUITS

Itisnotrecommendedthatoccupationalthera-pistsspendmorethan5to10minutesdoingvisionexercisesunlessmoretimehasbeenrecommendedbyastaffoptometristwithexpertiseinvisionandTBI.Although the exerciseswill not harm thepatient,theoptometristwillbeabletodeterminewhethertheexerciseswillbebeneficialorunneces-sarytothediagnosis.Occupationaltherapyinterventionemphasizes

thefunctionalimplicationsofpossiblevisionim-pairment.Therapistsaddressimpairmentsbygrad-ingfunctionalactivitiesandmonitoringpatients’abilityandsuccess.


Thereisminimaltonoobjectiveresearchdem-onstratingthattheuseofeyeexerciseswillbenefitpursuitdysfunctionforpatientswithc/mTBI;how-ever,basicrange-of-motionorfunctionalactivitiesthatusetheseskillswillnotharmapatientandmayimprovefunction.

Purpose/Background

Patientswithc/mTBImaydemonstrateimpair-mentwithpursuitsduringtheoccupationaltherapyvisionscreen.Thiscouldbeduetoavarietyofis-sues,including(butnotlimitedto)motorcontrol,poor innervation,damage to cranialnerves, andpoorvisualattention.Theoccupationaltherapist’srolesareasfollows:

• identifythepotentialimpairmentandhowitisaffectingthepatientfunctionally,

• referthepatienttoastaffoptometristwithexpertiseinvisionandTBI,

• educatethepatientabouttheimpairmentanditsfunctionalimplications,

• providecompensatoryintervention,and • providebasicrange-of-motionexercisesfor

theeyeandopportunitieswithintherapytoaddressvisualpursuitsduringvariousactivitieswhileaddressingotherareasoftreatment.

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° Provide compensatory strategies tomaximizefunction.

° Assign basic vision exercises, asappropriate.

° Introduce therapeutic activities thatincludevisualpursuitswhileaddressingother areas of occupational therapyintervention.

Intervention Methods

• Referpatienttoaneyespecialistforassess-mentandtreatment.

• Provideeducation. ° Provide individualized information

to thepatient abouthisorhervisionstrengthsandweaknessesandpotentialstrategies.

CLINICIAN TIP SHEET: TREATMENT IDEAS FOR PURSUITS

CLINICIAN TIP SHEET: INTERVENTION METHODS FOR PURSUITS

Education

What are Pursuits?

Pursuitsare“eyemovementsthatmaintaincon-tinuedfixationonamovingtarget.”27(p241)Examplesinclude:

• followingaballwithyoureyesinsports, • watchingpeopleoranimalswalkorrun, • followinganelectricalcordfromanap-

pliancetoanoutletwithjustyoureyes,and

• watchingapenorpencilwhilewriting.

Examplesofvisualpursuitswhentheobjectisstationaryandthepersonismovinginclude:

• readingasignorlookingatahousewhiledrivingbyinacar(onabike,etc),and

• lookinginthemirrorwhileturningyourheadtofixyourhair.

Whenan eyehas impairedpursuits, it isdif-ficultto:

• followmovingobjects(eg,youlosesightoftheballwhilewatchingsports),

• locatewhichcordgoestowhichappliancefromapowerstrip,or

• followthepenwhilewriting.

Compensatory Options

Compensatoryoptionsforpursuitsaresimilartothetechniquesusedforlowvisionandpooracuityandinclude:

• increasingillumination,contrast,andsizeofprint(enlarging);

• decreasingclutterandbackgroundpattern;and

• usingvisualmarkers (eg,usingaguideor finger toassist in lookingatdifferentobjects).

Thereisminimaltonoobjectiveresearchdem-onstrating that eye exerciseswill benefit visualpursuit impairment for patientswith c/mTBI;however,basiceyeexercisesorfunctionalactivitieswillnotharmapatientandmayassistinimprov-ing function (seeRange-of-MotionExercises). Ifthepatientcomplainsofdizzinessornauseawithrange-of-motion exercise, stop the exercise andfinda lessvisual tasktoworkon. If thepatienthasnotbeenreferredtoaneyespecialistalready,heorsheshouldbe.Following the exercise is a list of treatment

suggestionsthatusevisualpursuitskillswhilead-dressingothertreatmentareasaswell(Exhibit4-8).Theseactivitiescouldbeeasilyincorporatedintotreatmentwhileaddressingotherimpairments.

General Suggestions

• Startwithonlyoneeyeat a time (covertheothereyewithapatch)untilbotheyesaredoingtheexerciseequally.Onceeyesareabletodothetaskatthesamequality,performwithbotheyes.

• Havepatientkeephisorherheadstillandfocusonmovingtheeye(oreyes).

• Startwithsmallmovementsandprogresstolargermovements.

• Thisshouldonlytakeabout5minutesofsession timeunless recommendedby astaffoptometristwithexpertiseinvisionandTBI.

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elorpenlight)andaneyepatchoroccluder,movethetargetslowlybackandforthseveraltimesintoalldirectionsofview(eg,makea“+”andan“X”).

IMPAIRED SACCADES

Range-of-Motion Exercises

Usingatarget(eg,asmallballorobjectonadow-

Purpose/Background

Patientswith c/mTBImaydemonstrate im-pairmentwith saccadesduring theoccupationaltherapy vision screen. This could be due to avarietyof issues, including (butnot exclusively)motorcontrol,poorinnervation,damagetocranialnerves,andpoorvisualattention.Theoccupationaltherapist’sroleisasfollows:


• refer thepatient to anoptometristwithexpertiseinvisionandTBI,


• providecompensatoryintervention,and • providebasiceyeexercisesandopportuni-

tieswithintherapytoaddressvisualinef-ficienciesduringvariousactivitieswhilealsoaddressingotherareasoftreatment.

Itisnotrecommendedthatoccupationalthera-pistsspendmorethan5to10minutesdoingvisionexercisesunlessmore timehasbeen specificallyrecommendedbyastaffoptometristwithexpertiseinvisionandTBI.Althoughtheexerciseswillnotharm thepatient, theoptometristwillbeable todeterminewhethertheexerciseswillbebeneficialorunnecessarytothediagnosis.

Occupationaltherapyinterventionemphasizesthefunctionalimplicationsofpossiblevisionim-pairment.Therapistsaddressimpairmentsbygrad-ingfunctionalactivitiesandmonitoringpatients’abilitiesandsuccesses.


Thereisminimaltonoobjectiveresearchdemon-stratingthateyeexerciseswillbenefitvisualsaccadeimpairment forpatientswith c/mTBI;however,basiceyeexercisesorfunctionalactivitieswillnotharmapatientandmayimproveoculomotorcon-trolandmovement(andthusfunction).


• Referpatient toeyespecialist forassess-mentandtreatment.

• Education:provide individualized infor-mationtothepatientabouthisorhervisionstrengths andweaknesses andpotentialstrategies.

• Providecompensatorystrategiestomaxi-mizefunction.

• Assignbasicvisionexercises,asappropri-ate.

• Usetherapeuticactivitiesthatincludevi-sualsaccadeswhilealsoaddressingotherareasoftreatment.

CLINICIAN TIP SHEET: INTERVENTION METHODS FOR SACCADES

Education

What are Saccades?

Saccadesarequickeyemovements thatoccurwhentheeyesfixonvarioustargetsinthevisualfield.27Examplesinclude:

• reading(theeyejumpsfromonegroupofwordsandletterstothenext);

• lookingupinformationondisplays,charts,orphonebooks;

• lookingatphotosorpaintings;and • driving(lookingfromoneobjectorcarto

thenext).

Whenaneyehasimpairedsaccades,apatientmay:

• lose his or her placewhen reading orsearchingforinformation;

• missorskipwords,lines,orletters;and • notseesignificantobjectswhenlookingfor

them.

Compensatory Options

• Useaguideorfingertoassistinlookingatdifferentobjectsorwhenreading.

• Increaseprintsize. • Decreaseclutter.

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CLINICIAN TIP SHEET: TREATMENT IDEAS FOR SACCADES

Basic Saccade Exercise

General Setup

• Startwithonlyoneeyeat a time (coverothereyewithpatch)untilbotheyesaredoingtheexerciseequally.Onceeyesareabletodothetaskatthesamequality,per-formtheexercisewithbotheyestogether.

• Havethepatientkeephisorherheadstillandfocusonmovingtheeye(oreyes).

• Startwithlargemovementsandprogresstosmallermovements.

Procedure

• Usetwotargets(eg,asmallballorobjectonadowel,penlight,orfingers)andaneyepatchoroccluder.Askthepatienttolookbackandforthbetweenthetwotargets.

• Startslowly,holdingthegazeforseveralseconds,andmovebackandforthbetweentargets.Aspatient improves, graduallyincreasespeed.

• Movetargetssopatientmovesgazeintodifferentdirectionsofview(eg,havethetargetsasifattheendpointsofaplussignandanX;movesidetoside,upanddown,diagonal).

• Thisshouldonlytakeupabout5minutes.

Alternate Saccadic Exercise

General Setup

• Startwithoneeyeatatime(covertheothereyewithapatch)untilbotheyesaredoingtheexerciseequally.Onceeyesareabletodotaskatthesamequality,performwithbotheyestogether.

• Havepatientkeephisorherheadstillandfocusonmovingtheeye(oreyes).

• Startwithlargemovementsandprogresstosmallermovements.

Procedure

• Usecolumnsofnumbersorlettersonpaper(smalldistance saccades)oronagreaseboard (largerdistance saccades) andaneyepatchoroccluder.

• Havepatientreadthetwocolumnslefttoright,movingfromtoptobottom.

• Asneeded,havethepatientusefingersorotheranchors,progressingtonoanchors.

• Usestopwatchtodocumentprogress. • Changespeedusingametronome. • Startwithtwocolumns,thenincreasethe

numberofcolumns. • Thisshouldonlytakeabout5minutes.

Incorporate activities that challenge saccadicmovement into the therapy recommendations(Exhibit4-9).

IMPAIRED ACCOMMODATION

Purpose/Background

Patientswith c/mTBImaydemonstrate im-pairedaccommodation.Theymayreportdiscom-fortandeyestrainwithneartasks,blurredvision,visual fatigue, ordifficulty changing focus fromneartofarandfartonear.Theoccupationalthera-pist’sroleisto:


• refer thepatient toastaffoptometristorophthalmologistwithexpertise invisionandTBI,

• educatethepatientabouttheimpairment

anditsfunctionalimplications, • provide compensatory intervention if

needed,and • providebasiceyeexercisesandopportuni-

tieswithintherapytoaddresstheimpairedaccommodation.

It is not recommended that occupationaltherapistsspendmorethan5to10minutesdo-ingvisionexercisesunlessmore timehasbeenspecifically recommended by an optometrist.Althoughtheexerciseswillnotharmthepatient,theoptometristwillbeabletodetermineif theexerciseswillbebeneficialorunnecessarytothediagnosis.

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EXHIBIT 4-8

FUNCTIONAL ACTIVITIES TO ADDRESS PURSUITS

Paper-and-Pencil Tasks

• Linescrambles • Mazes • Computergames(slow-movingobjects) • Remote control car (move throughob-

staclecourse)

Also Improves

º Attentionspan º Hand-eyecoordination º Problemsolving º Preplanning

Penlight on the Wall

• Traceashapeormovementoutlinedonthewall

• Identifylettersornumbersonthewall

Also Improves

º Hand-eyecoordination º Upper extremity strength and

coordination

Ball Games

• Bounceagainstawallandcatch • Ballonastring(trackandhit) • Playcatch • Balloonvolleyball(trackingandbursting

bubbles) • Beanbagtoss

Also Improves


coordination º Bilateralhandtasks

Dynavision(WestChester,OH;seeClinicianTipSheet:DynavisioninSupplementaryTherapeuticActivityOptionssectionforinformationabouttheDynavision)

• ModeC(outercircletracking)

Also Improves

º Upper extremity strength andcoordination

EXHIBIT 4-9

FUNCTIONAL ACTIVITIES TO ADDRESS SACCADES

Copy Tasks

• Telephonenumbers • Words • Sudoku • Writechecksfromlist • Enterchecksinregister

Also Improves

º Attentionspan º Hand-eyecoordination º Handwriting º Problemsolving º IADLtasks

Card Games

• Solitaire:tableorcomputer • War:usemetronometoincreasespeed • Jigsawpuzzles:beginsimpleand large

andprogress • Computergames:slow

Also Improves


coordination º Bilateralhandtasks º Problemsolving º Preplanning

Dynavision (WestChester,OH)

• ModeA • ModeB • ModeAwithdigits

Also Improves


coordination º Reactiontime º Divided attention (modeAwith

digits)

IADL:instrumentalactivitiesofdailyliving

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ThecompensatoryinterventionsincludedinthissectionarefoundinScheiman,Understanding and Managing Vision Deficits: A Guide for Occupational Therapists.15


Referpatient to eye specialist for assessmentandtreatment.SeeClinicianTipSheetforeduca-tion,instructionsincompensatorystrategies,andexercises.

Education

What is Impaired Accommodation?

Accommodation is the ability of the eyes tofocus at various distances (including shiftingfromonedistancetoanother).AccordingtoSchei-man andWick, “it also permits the individualtomaintain clear focus at the normal readingdistance.”40(p697)Thereisanaturaldeclineinac-commodative ability from childhood throughadulthood.Thisdeclinereachesacriticallevelatabouttheageof40to45years,whichistheagewhenmostadultsbegintonoticeblurredvisionwithreading.If someonedemonstrates impairedaccommo-

dation(asevidencedbydiscomfortandeyestrainwithneartasks,blurredvision,visualfatiguewithneartasks,ordifficultychangingfocusfromneartofarandfartonear),heorshemayhaveimpairedaccommodation.Thismayoccurduetoimpairedinnervation.

Symptoms of Impaired Convergence

• Complaintsofdiscomfortandeyestrainwithvisualtasks

• Complaintsofblurriness • Eyerubbing • Complaints of visual fatiguewith near

tasks • Easyfatiguewithvisualtasks • Inattentionwithvisualtasks • Difficultyconcentratingontasks • Difficultywithtasksthatrequiresustained

closework

Symptomsmay occur at different times andintervals(ie,allthetime,atdifferenttimesofday,intermittently,oronlywhenfatigued).

Functional Implications

• Readingorneartasksmaybedifficult(eg,inabilitytomaintainfocus)

• Visionblurriness • Difficulty adjustingvisualdistances (eg,

whiledriving, looking at the road thenlookingatthedashboard)

• Inattentionwithvisualtasks

Compensatory Strategies

Specific Accommodation Compensatory Strategies

• Ifglassesareprescribed,ensurecompliancewithwear.

• If bifocalshavebeenprescribed, ensurepatientdoes closeworkwhileusing thebottomofthebifocal.

• Largerprintmayhelprelievesymptomsuntiltreatmentiscomplete.

• Takefrequentbreaks.15(p140)

General Compensatory Strategies

The compensatory options are similar to thetechniquesusedforlowvisionandpooracuity.Re-fertoPoorAcuity,CompensatoryTechniquesandTeachingforfurtherdetail.Otheroptionsincludethefollowing:

• increaseillumination,contrast,orprintsize(enlarge);

• decreaseclutterandbackgroundpattern; • usevisualmarkers; • useaguideorfingertoassist inlooking

atdifferentobjects,orrulersoranchorstoavoidlosingplace;

• avoidglare; • limit timedoing visual tasks that take

concentration;and • takefrequentbreaks.

Selected Reference


CLINICIAN TIP SHEET: INTERVENTION METHODS FOR IMPAIRED ACCOMMODATION

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IMPAIRED CONVERGENCE

Purpose/Background

Patientswith c/mTBImaydemonstrate im-pairedconvergence.Thepatientmaycomplainofeyestrain,headache,ordifficultieswithneartasks.Theoccupationaltherapist’sroleisto:


• referthepatienttoastaffoptometristwithexpertiseinvisionandTBI,


• provide compensatory intervention ifneeded,and

• providebasiceyeexercisesandopportuni-tieswithintherapytoaddresstheimpairedconvergence.

Itisnotrecommendedthatoccupationalthera-pistsspendmorethan5to10minutesdoingvisionexercisesunlessmoretimehasbeenrecommendedbyastaffoptometristwithexpertiseinvisionandTBI.Althoughtheexerciseswillnotharmthepa-

tient,theoptometristwillbeabletodetermineiftheexerciseswillbebeneficialorunnecessary tothediagnosis.


Thecompensatoryinterventionsincludedinthissectionarewidelypresentedintextbooksandlitera-turerelatedtovisiondeficits.Thereisminimaltonoobjectiveresearchdemonstratingthateyeexerciseswill benefit complaintsof impaired convergenceforpatientswithc/mTBI;however,thereisstrongevidencethatinterventionimprovesconvergenceinchildrenandadults,41includingonerandomizedcontrolledtrialthatreportedsuccessinalleviatingsymptomsofconvergenceinsufficiencyinyoungadults,asitaffectedreadingandclose-upwork.42


Referpatienttoaneyespecialistforassessmentandtreatment.Seecliniciantipsheetforeducationand instructions in compensatory strategies andbasiceyeexercises.

Selected References

LavrichJB.Convergenceinsufficiencyanditscurrenttreatment.Curr Opin Ophthalmol. 2010;21(5):356–360.

ScheimanM,MitchellGL,CotterS, et al.A randomized clinical trial ofvision therapy/orthopticsversuspencilpushupsforthetreatmentofconvergenceinsufficiencyinyoungadults.Optom Vis Sci. Jul2005;82(7):583–595.

CLINICIAN TIP SHEET: INTERVENTION METHODS FOR IMPAIRED CONVERGENCE

fusionwithdistancetasks).Thetreatmentsugges-tions inDiplopia (below)will address impaireddivergence.Referraltoaneyespecialistisrecom-mended.Impairedconvergencemaybeduetopoorin-

nervationormotorcontrol,ormayresultfromalongstanding eyemuscleproblem that becomesdecompensatedafterTBI.

Symptoms

• Doublevisionorblurrinesswithup-closetasks

• Headachesordifficultywithneartasks • Wordsmovingwhentryingtoread • Eyestrain • Squintingoneeye • Difficultyconcentratingontasks • Turningtheheadtoseeanobjectclearly

Education

What is Impaired Convergence?

Normallywheneyesareworkingtogethertheyareable toconvergeandfocus(fuse)onasingleitemorobjectandmaintainthefusionastheobjectmovescloser to theeyes,until it isabout2 to4inchesfromtheeye.Theeyesshouldbeabletofuseagainwhentheobjectismoved4to6inchesaway.If someonedemonstrates impaired convergence(asevidencedbyoneeyemovinglaterallyaway,complaintsofdoublevision,orsignificanteyestrainwhenbringingthetargetclosetotheeyes),heorshemayhaveimpairedconvergence.Ifapatientisabletoconvergeandmaintainfu-

sionupclosebutcomplainsofdoublevisionasanobjectmovesout,thepatientmayhaveimpaireddivergence(difficultyallowingtheeyestomaintain

132



• Stationaryobjectsmayappeartomove. • Readingmaybedifficult(eg,skippingover

words,losingone’splace). • Headachesandblurrinessmayoccur.

Symptomsmay occur at different times andintervals(eg,allthetime,atdifferenttimesofday,intermittently,onlywhenfatigued).Impairedcon-vergencemayoccurwhen looking intodifferentfieldsofvision,aswell(eg,straightahead,toonesideoranother,inthesuperiororinferiorfields,oranycombinationordirection).



Patching

Patching is a short-termmethod tomanageimpaired convergence so the patient is able tofunction. If thepatientdoesnot complainof theaforementioned symptoms,patching is inappro-priate; however, if apatient is havingdifficultywithreadingornear tasksdue todoublevision,headaches,andthelike,thismaybeatask-specificcompensatorytechniqueallowingpatientstoreadorperformotherup-closetasks.Todeterminewhich eye isdominant, ask the

patienttorollupastandard-sizedsheetofpapertocreateapaperspyglass.Askthepatientto“spy”anobjectontheothersideoftheroom,thenwatchwhich eye thepatient automaticallyuses todoso.Thepatientwillautomaticallyselecthisorherdominanteyetousewiththespyglass.Patchingshouldonlybedoneduringthetimes

whenthepatientcomplainsofdifficultyperform-ingneartasks(eg,intermittentlyorwhenfatigued).Unlessapatienthaspooracuity inoneeyeor isunabletoadequatelymoveoneeye,alternatewhicheyeispatchedeachday.Patchesmaybetranslucentor opaque.There are threeoptions forpatching(Figure4-8):

1. Partialpatching:nasalfieldofnondomi-nanteye.

2. Partialpatching:centralspotpatchingonnondominanteye.

3. Full occlusion (less frequently recom-mended): reduces vision to single eye,therebyeliminatingdoublevision.How-ever,patientlosesperipheralvision,willsustaineye fatigue,andtherearesafetyconcernsduetovisionloss.

NOTE:Interventionforimpairedconvergencethatinvolvespatchingmustbedirected/guidedbyaneyecareprovider.


Thecompensatoryoptionsaresimilartothetech-niquesusedforlowvisionorpooracuity,asfollows:

• Increaseillumination,contrast,orprintsize(enlarge).

• Decreaseclutterandbackgroundpattern. • Usevisualmarkers,suchasaguideorfin-

gertoassistinlookingatdifferentobjects,orrulersoranchorstoavoidlosingplacewhenreading.

• Avoidglare. • Limit timedoingvisual tasks that take

concentrationandtakefrequentbreaks.


Treatment Ideas

Althoughthereisminimalresearchdemonstrat-ingthateyeexerciseswillbenefitimpairmentcon-vergenceforpatientswithc/mTBI,thereisstrongevidencesupportingitseffectivenesswithchildrenand adults.41,42 Basic eye exercises or functionalactivitieswillnotharmapatientandmayimprovefunction.Ifthepatientreportsdizzinessornauseawiththisexercise,stoptheexerciseandfindalessvisuallydemandingtasktoworkon.

NOTE: OccupationaltherapistsincorporateeyeexercisesintotheirtreatmentplansinconsultationwithandundersupervisionofoptometristswithexpertiseinTBI.

Pencil Pushups

This exercise uses both eyes together. Oureyesmust come together smoothly and evenlywhenwedonearactivities, suchas readingorneedlework.

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twopencils are seen orwhen one eyemovesaway.

2. Slowlymove the pencil away severalinchesbeyondthepointthetwoimagesturnintoone(orthedeviatedeyemovesback into focus on the target and theeyes are fusedon the target together).Thegoalistokeeptheeyesturninginandfocusingonthepencilasitismovedclosertothenose.Theimageofthepen-cilshouldstaysingleasitmovesallthewaytothenose(within2to4inchesoftheeyes).

3. Repeattheexercise5times,thenrestfor1to2minutesandbeginagain.

The therapistmustbe sure thepatient’s eyesaremovinginandconvergingonthetarget.Ifoneeyedeviates,stopandbringthetargetbackuntiltheeyesarefusedonthetargetagain.Donothaveapatientdothisaloneifheorsheisnotawareoftheeyeslosingfusion.Ifthepatientcomplainsofdoublevisionthroughouttherange,thisexerciseisinappropriate.

1. Holdatarget(pen,smallballorobjectonadowel,penlight)atarm’slengthdirectlyinfrontofthepatient’snose.Slowlymovethepencilintowardthenose.Stopwhen

Figure 4-8.Visualocclusionoptionsfordiplopia.Fullvisualoc-clusion(eg,“piratepatch”;topimage)willresultinthepersonseeingone image, but secondary complications include lossofperipheralvision,bodyimageissues,andsoon.Partialoc-clusioncanbedonewithspotpatchingwithtranslucenttape(middle)andoccludingthenasalfieldofthenondominanteye(bottomimage).

Full occlusion(”pirate patch”)

Partial occlusion– spot patchingwith translucenttape

Partial occlusion– nasal fieldocclusion with translucent tape

DIPLOPIA

invisionandTBI.Althoughtheexerciseswillnotharm thepatient, theoptometristwillbeable todetermineiftheexerciseswillbebeneficialorun-necessarytothediagnosis.


Thecompensatory interventions included inthis section arewidely presented in textbooksand literature related to vision deficits. Thereisminimaltonoobjectiveresearchdemonstrat-ing that the use of eye exerciseswill alleviatecomplaintsofdoublevisionforpatientswithc/mTBI;however,basiceyeexercisesorfunctionalactivitieswill not harmapatient andmay im-prove oculomotor control andmovement (andthusfunction).


Referpatienttoaneyespecialistforassessmentandtreatment.Seecliniciantipsheetforeducationand instructions in compensatory strategies andbasicrange-of-motionexercises.

Purpose/Background

Patientswithc/mTBImayreportdoublevision.Thecomplaintsofdoublevisionmaybeintermit-tent,locatedinvariouslocationsofthevisualfield,orcomeaboutwhendoingdifferentkindsoftasks.Theoccupationaltherapist’srolesareto:

• Identifythepotentialimpairmentandhowitisaffectingthepatientfunctionally.

• ReferthepatienttoastaffoptometristwithexpertiseinvisionandTBIwhowillbeabletotellifitisamonocularorbinocularissue.

• Educatethepatientabouttheimpairmentanditsfunctionalimplications.

• Providecompensatoryintervention. • Providebasiceyeexercisesandopportuni-

tieswithintherapytoaddressthedoublevision.

Itisnotrecommendthatoccupationaltherapistsspendmore than 5 to 10minutes doing visionexercisesunlessmore timehasbeen specificallyrecommendedbyastaffoptometristwithexpertise

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CLINICIAN TIP SHEET: INTERVENTION METHODS FOR DIPLOPIA

Education

What is Double Vision?

Normallywhentheeyesareworkingtogether,theyareabletoconvergeandfocus(fuse)onasingleitemorobject.Ifsomeonereportsdoublevisionthatdisappearswhenoneeyeisclosed,thepatientmostlikelyhasbinoculardiplopiaandmaybeunabletoholdbotheyesfocusedonanitemorobjectatthesametime;thus,thebrainreceivestwodifferentim-ages.Ifthedoublevisiondoesnotdisappearwithclosingoneeye,itismonocular;interventioninthisrealmisoutsidetheoccupationaltherapist’sscopeofpractice.Eitherway,thepatientshouldbeseenbyaneyecareprofessional.Themostlikelycauseofdoublevisionismisalignmentoftheeyes,whichmaybedue topoor innervationof eyemuscles,poor oculomotor control, inflammation,muscleadhesions,orobstructions.

Symptoms

• Doublevision • Blurriness

• Difficultywithneartasks • Wordsmovingwhenreading • Headacheswithneartasks • Eyestrain • Squintingoneeye • Difficultyconcentratingontasks • Turningtheheadtoseeanobjectclearly

Symptomsmay occur at varying times andintervals(eg,allthetime,atdifferenttimesofday,intermittently,onlywhenfatigued,onlywhendo-ingneartasks,onlywhenlookinginthedistance,orwhenlookingnearandfar).Doublevisionalsomayoccurwhenlookingintodifferentfieldsofvi-sion(eg,straightahead,toonesideoranother,inthesuperiororinferiorfields,oranycombinationordirection).


• Decreaseddepthperception. • Stationaryobjectsmayappeartomove. • Readingmaybedifficult(eg,skippingover

words,losingone’splace). • Headachesandblurrinessmayoccur.

CLINICIAN TIP SHEET: INTERVENTION METHODS FOR DIPLOPIA


Patching

Patchingisashort-termmethodtomanagedip-lopiasothepatientisabletofunction(seeFigure4-8).Thethreepatchingoptionsinclude:

1. Partialpatching:nasalfieldofnondomi-nanteye.

2. Partialpatching:centralspotpatchingonnondominanteye.

3. Full occlusion (less frequently recom-mended): reduces vision to single eye,therebyeliminatingdoublevision.How-ever,patientlosesperipheralvision,willsustaineye fatigue,andtherearesafetyconcernsduetovisionloss.

Todeterminewhich eye isdominant, ask thepatienttorollupastandard-sizedsheetpapertocreateapaperspyglass.Askthepatientto“spy”anobjectontheothersideoftheroomandwatchwhich eye thepatient automaticallyuses todoso.Thepatientwillautomaticallyselecthisorher

dominanteyetousewiththespyglass.Patching can be translucent or opaque and

should only be donewhen the patient reportsdoublevision(maybeintermittentoroccurwhenthepatientisfatigued)orallthetimeifoneeyeisnoticeablyoutofalignment.Unlessapatienthaspooracuityinoneeyeorisunabletoadequatelymoveone eye, alternate the eye that ispatcheddaily.


Thecompensatoryoptionsaresimilartothetech-niquesusedforlowvisionorpooracuity,including:

• increaseillumination,contrast,orprintsize(enlarge);

• decreaseclutterandbackgroundpattern; • usevisualmarkers,suchasaguideorfin-

ger,toassistinlookingatdifferentobjectsorrulersoranchorstoavoidlosingplacewhenreading;

• avoidglare;and • limit timedoing visual tasks that take

concentrationandtakefrequentbreaks.

135


VISUAL FIELD LOSS

twoarticlesforvisualfielddeficitsafterstrokemettheir criteria for inclusion,neitherofwhichhadstrongrecommendationsduetolackoffunctionaloutcomesandstudylimitations.AstudybyWar-renandcolleagues37addressedthetypesofsearchstrategiesusedbyhealthyadults.


• Referpatient toeyespecialist forassess-ment(visualfieldtest).

• Educatepatient. • Teachpatientstousecompensatorytech-

niquesforfieldlosssuchas: ° useofanchorsandrulers, ° visualsearchstrategies, ° large-andsmall-scaleeyemovements, ° increasedheadturns,and ° increasedattentiontodetail. • Employactivitiesforengagingpatientsto

addressvisualfieldloss.

Purpose/Background

Individualswith TBImay experience visualfieldloss.43Althoughvisualfieldlossistypicallynot associatedwith c/mTBI, clinicians need tounderstand this issue in case theirpatientshaveexperienced complicatedmTBI ormore severeinjuries.Lossofvision in thevisual field canbedisorientingandgivesanarrowerscopeofuseablevision.Apersonmaymissdetailsornotseecriticalinformationorobjects.Once the lossofvision isidentifiedanddefined,theoccupationaltherapist’sroleistoeducatethepatientandteachcompensa-tory techniques so thepatient canparticipate intherapyandfunctioninhisorhereverydaylife.


There is little empirical literature to informpracticeinthisarea.Riggsandcolleagues43didasystematicreviewoftheliteratureandfoundonly

Selected References

RiggsRV,AndrewsK,RobertsP,GilewskiM.Visualdeficitinterventionsinadultstrokeandbraininjury:asystematicreview. Am J Phys Med Rehabil. Oct2007;86(10):853–860.

WarrenM,MooreJM,VogtleLK.Searchperformanceofhealthyadultsoncancellationtests.Am J Occup Ther. Sep-Oct2008;62(5):588–594.

CLINICIAN TIP SHEET: INTERVENTION METHODS FOR VISUAL FIELD LOSS

seeingsigns,reading,andwriting;inabilitytofindhigherplaceditems

• Inferior field loss: causesdifficultywithmobility(clearingcurbs,steps,rugs,lowfurniture), slower pacedwalkingwithshortenedstride,walkingbehindothers,trailingbehindothers,andpoorbalance

• Lateral field loss: leads tobumping intothings,missingitemsonthesideaffected

• Lossinanyfield:resultsindifficultyread-ingandwriting,misidentificationofdetailsor longwords, anddifficulty findingorbeingawareofobjectsintheaffectedfield.


Becausevisualfieldlosscanbedisorientingandconfusingforpatients,itmaybenecessarytoteachpatientshowtousetheirvisionagainwiththenewimpairment (formoreon teachingand learningmethods,seeChapter7:CognitiveAssessmentand

Education

Itisessentialthatpatientswithvisualfieldlossunderstandwhathashappenedtotheirvisionandhowitwillinterferewithvariousactivities.

What is a Visual Field Loss?

Visualfieldsarethetotalareavisibletoaneyethatisfixatingstraightahead,measuredindegreesfromfixation.44Visualfieldlossisthelossofvisioninaspecifiedareaofvision.Theareaoftheinjuryorlesionalongthevisualpathwaydeterminesthefieldlosslocation.Visualfieldlosscanbeinanyareaofthevisualfieldandcanbedifferentineacheye.

Functional Implications of Specific Types of Field Loss

• Centralfieldloss:leadstodecreasedacuity • Superior field loss: results in difficulty

136


• Structure:taskorganization(ie,startwithorganized, simple structure andmovetowardrandom)

• Speed: startwith slow,deliberatemove-mentandworktowardincreasingspeed.

Size of Treatment Tasks

• Largetasks(fullroomandlarger,5feetormoreaway)

• Smalltasks(paper,pencil,andtabletop)

Scanning Patterns of Healthy Adults

Warrenandcolleagues37foundthescanningpatternpredominantlyusedbyhealthyadultswerestructuredpatterns,withastrongtendencyfor left to right, and top to bottom scanningpatterns.

Intervention, specificallyTechniques toPromotePatientEngagementandLearning).FortreatmentactivityideasseeTable4-4.

Techniques to Teach the Patient

• Visualsearchstrategies(tomaximizeorga-nizationandefficiency),includingleft-to-rightforreading.Startinatthefarendoftheaffectedside,useacircularpatternforlargerscanningactivities.

• Large-scale eyemovements formobilityandscanningintheenvironment.

• Small-scaleeyemovementsforreadingandneartasks.

• Increasedhead turns, especially into theaffectedarea.

Increased Attention to Detail

• Promotesensuring thatpatient sees intotheareaaffected.

• Watchingthepenorpencilwhenwriting.

Using Anchors and Rulers

• Usearulertokeeptrackofeachlinebeingread.

• Useabrightcoloredlineorrulerverticallyat theedgeof thetextonthesideof themissing field to ensure finding theedgeofthetext.

Approaching Treatment Tasks

Grading the Tasks Using Activity Analysis

• Density:lowdensitytohighdensity(eg,startwithtwocolumnsofletters,oneoneachsideofthepage,andprogresstotencolumnsofletters)38

VISUAL NEGLECT AND INATTENTION

sideofabrainlesionthatcannotbeattributedtosensory ormotor dysfunction.46Apersonmaybumpintodoorframeswhenambulating,readonlypartiallinesorwords,missdetails,ornotseecriticalinformationorobjects.Oncetheneglectorinatten-tionisidentified,theoccupationaltherapist’sroleistoeducatethepatientandteachcompensatorytechniquessothepatientmayparticipateintherapyandfunctionineverydaylife.

Purpose/Background

Individualswith TBImay experience visualneglectorinattention.45Althoughnottypicallyasso-ciatedwithc/mTBI,cliniciansneedtounderstandthis issueincasetheirpatientshaveexperiencedcomplicatedmTBIormoresevereinjuries.Neglectisafailuretoreport,respond,ororient

tonovelormeaningfulstimulionthecontralesional

TABLE 4-4

DIFFERENCES BETWEEN FIELD CUT AND NEGLECT

Field cut Neglect

• Awarenessemergesearly

• Compensatory strategies observedearly,easilytaught

• Earlyeye movement to affectedside

• Organized

• Lackofawarenessmore persistent

• Compensatory strategiesarehardtolearn,maynotbeeffective

• Rightwardgaze preference

• Random

Data source:Gillen G. Cognitive and Perceptual Rehabilitation: Optimizing Function.StLouis,MO:Mosby;2009.

137



• Refer patient to an eye specialist forassessment.

• Providepatienteducation. • Teachthepatientcompensatorystrategies,

including: ° useofanchorsandrulers, ° visualsearchstrategies(organizedand

efficient), ° large-andsmall-scaleeyemovements, ° increasedheadturns,and ° increasedattentiontodetail. • Employactivitiesforengagingpatientsto

addressneglectandinattention.


There is little empirical literature to informpractice in thisarea.Bowen47didasystematicreviewof the literature andonly found12ar-ticlesforvisualfielddeficitsafterstrokethatmetcriteriaforinclusion.Hefoundtherehabilitationtreatments that targetedneglectdemonstratedtest improvement (eg, finding visual targetsormarkingmidpoints of lines); however, thefunctional implications for performing every-dayactivitiesorindependentlivingskillswereunclear.A study byWarren and colleagues37 addressed the types of search strategies usedbyhealthyadults.

Selected References

BowenA,LincolnN.Cognitiverehabilitationforspatialneglectfollowingstroke.The Cochrane Library. 2009;4.

CherneyLR.Unilateralneglect:adisorderofattention.Semin Speech Lang. 2002;23(2):117–128.

CockerhamGC,GoodrichGL,WeichelED,etal.Eyeandvisualfunctionintraumaticbraininjury.J Rehabil Res Dev. 2009;46:811–818.


HeilmanKM,WatsonR,ValensteinE.Neglectandrelateddisorders. In:HeilmanKM,ValensteinE,eds.Clinical Neuropsychology.3rded.NewYork,NY:OxfordUniversityPress;1993:279–336.

MesulamMM.Attention,confusionalstatesandneglect.In:MesulamMM,ed.Principles of Behavioral Neurology. Hove, England:Erlbaum;1985:173–176.

CLINICIAN TIP SHEET: INTERVENTION METHODS FOR VISUAL INATTENTION AND NEGLECT

Spatial Domains of Neglect

• Personalbodyspace.Patientstendtoig-nore the left side (contralesional side)oftheirbody,whichcanresultinadeficitingroomingordressing.

• Peripersonal space.Neglect is observedwith tabletoppencil-and-paper tasks innearspacewithinreachorgrasp.

• Extrapersonalspace.Neglectisobservedwithenvironmentalscanninginfarspacebeyondreach.48

Categories of Attentional Deficits

• Action-intentional disorders (motor ne-glect):failureordecreasedabilitytomoveintocontralesionalspace

• Inattention (sensoryneglect): lackorde-creasedawarenessofsensorystimulationincontralesionalspace

Education

It isessential thatpatientswithvisualneglect(withorwithout avisual field loss)understandwhathashappenedtotheirvisionandhowitwillinterferewithvariousactivities.

The Difference Between Visual Field Loss and Visual Neglect

Inattention/Neglect is a failure to report, re-spond,ororienttonovelormeaningfulstimulionthecontralesionalsideofabrainlesionthatcannotbeattributedtosensoryormotordysfunction.46

Visual Field Deficitisanareavisibletotheeyewhenitisfixatedstraightahead.Itismeasuredindegreesfromfixation.44Visualfieldlossisthelossofvisioninaspecifiedareaofvision.Theareaoftheinjuryorlesionalongthevisualpathwayde-terminesthefieldlosslocation.

138


• Notbeingawareof thepersonsittingorstandingtopatient’sleftside

• Notbeingable to findobjects to the leftsideofthesinkorcounter

• Reading:startingtoreadinthemiddleofa line,missing thebeginning lettersofaword,orlosingone’splacewhenreading

• Ambulating:bumping intodoorwaysorfurniture, not looking to the leftwhencrossingthestreet

• Memory and representational deficits:deficitoftheinternalrepresentationofthecontralesionalspaceorlimbs46,49

Functional Implications of Neglect

• Notpayingattentiontoor“seeing”peopleandobjectsonpatient’sleftside(specifi-cally,leftneglect)

• Missingthefoodontheleftsideoftheplate

Insight and awareness are key to a patient’scompensationwithneglect(whichischallenging;patientslackinsightandawarenessduetothede-creasedattention).50

Response to Treatment and Education

Treatmentactivitiesandcompensatorystrategiesaresimilartovisualfielddeficits;however,thera-pistsneedtoadapttreatmentapproachestoallowfor increased treatmentduration and frequencyofrepetition(seeTable4-4).FortreatmentactivityideasseeTable4-5.

Techniques to Teach the Patient

Visual Search Strategies

Tomaximizeorganizationandefficiency,teachpatientsthefollowingtechniques:

• readinglefttoright, • startinginatthefarendoftheaffectedside,

and • usingacircularpatternforlargerscanning

activities.

Large-scaleeyemovementsareusefulformobil-ityandscanningintheenvironment.Small-scaleeyemovementshelpwithreadingandneartasks.Increasingheadturnsishelpfulespeciallyintoaf-fectedarea.

Increased Attention to Detail

• Promotes ensuring that thepatient seesintotheareaaffected.

• Encourage patient towatch the pen orpencilwhenwriting.

Using Anchors and Rulers

• Usearulertokeeptrackofeachlinebeingread.

• Useabrightlycoloredlineorrulerverti-callyattheedgeofthetextonthesideofthemissingfieldtoensurefindingtheedgeofthetext.

Approaching the Treatment Tasks

Grading the Tasks Using Activity Analysis

• Density:lowdensitytohighdensity(eg,startwithtwocolumnsofletters,oneoneachsideofthepage,andprogresstotencolumnsofletters).

• Structure:organizationofthetask(ie,startwithorganizedsimplestructureandmovetowardsrandom).

• Speed: startwith slow,deliberatemove-mentandworktowardincreasingspeed.38

Size of Treatment Tasks

• Largetasks(fullroomandlarger,5feetormoreaway)

• Smalltasks(paper,pencil,andtabletop)

Scanning Patterns of Healthy Adults

Warrenandcolleagues37foundthescanningpatternpredominantlyusedbyhealthyadultswasstructuredpatterns,withastrongtendencyfor left to right and top to bottom scanningpatterns.

CLINICIAN TIP SHEET: TREATMENT APPROACH TO VISUAL INATTENTION AND NEGLECT

139


GLARE/PHOTOPHOBIA MANAGEMENT

Purpose/Background

Patientswithc/mTBImayreportphotophobia.51 They canbe sensitive to specific kindsof lights(eg, fluorescent lightsmay causea flicker effect)ordifferentweatherconditions(eg,brightsunorclouds),amongotherthings,whichcanleadtocom-plaintsofheadaches,lightintolerance,squinting,andfrequenteyeclosing.Occupationaltherapistscanhavearoleinidentifyingpatientswiththesecomplaintsandprovidingoptions thatminimizesymptomsandhelppatientsparticipateintherapyandeverydayactivities.


There isno specific evidence to inform inter-ventionforphotophobiaassociatedwithc/mTBI.

However,asmallstudyconductedbyJackowskiand colleagues51 demonstrated visual function(reading)improvementwiththeuseoflight-filter-inglensesforpatientsfollowingTBIwhoreportedphotophobia (N=14). It shouldbenoted that thestudywasconductedindoorsonly.


• Referpatient toeyespecialist forassess-mentandtreatment.

• Educatepatient. • Teachcompensatorystrategies.

Selected Reference

JackowskiMM,SturrJF,TaubHA,TurkMA.Photophobiainpatientswithtraumaticbraininjury:usesoflightfilter-inglensestoenhancecontrastsensitivityandreadingrate.Neurorehabilitation. 1996;6:194–201.

TABLE 4-5

ACTIVITIES TO ENGAGE PATIENTS

Visual Scanning Activity Works On

• Paper-and-pencilactivities(cancellationtasks,reading, Nearscanningforreturntoreading(books,maps,etc)mazes,wordsearchpuzzles,crosswordpuzzles)

•Prereadingandwritingexercises*

•Easelortablewithcardmatching Mid-distancescanningforIADLs(mealpreparation, •Cardandgamesonatable billpaying,shopping,etc) •Finditemsonshelforcupboard • Jigsawpuzzles(spreadoutontable) •Hittingaballagainstawallturnedsidewayssothe

visualfieldlossistowardsthewall •Dynavision† •NVTScanningDevice‡

•NeurovisionRehabilitator§

• Identifyallobjectsinaroom Distantactivitiesforlookingfarandformobility •Walkdownahallwayandidentifywhatisonthewall

(orplacestickynoteswithnumbersorlettersonthem) •Walkthroughobstaclecourse •Doascavengerhuntofobjectsintheclinic

IADLs:instrumentalactivitiesofdailyliving*FromvisABILITIESRehabServicesInc(Hoover,AL).Includesvariouspaperpencilactivities.† FromDynavision(WestChester,OH).Allmodes.‡FromNeuroVisionTechnologySystems(Torrensville,SA,Australia).§ TheNeuro-VisionRehabilitator(http://nvrvision.com).

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CLINICIAN TIP SHEET: INTERVENTION METHODS FOR GLARE/PHOTOPHOBIA

PhotochromicFiltersCPF450, 527-S, and550-S;Corning,Inc,AvonCedex,France)which significantly improved (P< 0.01)thereadingratesoftheTBIsubjectswithphotophobia.Outdoor settingswerenottested.Theseare commerciallyavailableateyeglassstores.Otheroptions includeNoIR andUVShield sunglasses (NoIRMedicalTechnologies,SouthLyon,MI).

• Encouragethepatienttoweanofftintedglassesovertime.

• Encourageuseofbaseballhatsandvisors;havesomeavailableintheclinicfortrialoruse.

• Limit overhead light use and use tasklights.

Education

PhotophobiacanbeacommoncomplaintafterTBI.Themechanismisnotclearatthistime.


Thepatientshouldbereferredtoaneyespecial-ist;however,anoccupationaltherapistcanhelpthepatientbeasfunctionalaspossibleusingcompensa-torystrategies.Someoptionsincludethefollowing:

• Tinted glasses (color anddensity needto be tried todetermine optimal visualclarity and comfort). For indoors,51 usethree photochromatic filters (Corning

SUPPLEMENTARY THERAPEUTIC ACTIVITY OPTIONS

Strength of Recommendation: Practice Options


• Dynavision 2000 Light Training Board(WestChester,OH)forvisualfielddeficits.

• Prereadingandwritingexercises. • NeuroVisionTechnology(NVT)Scanning

Device(NVTSystemsPtyLtd,Torrensville,SA).

• NeurovisionRehabilitator (NVR;www.nvrvision.com).

Purpose/Background

Whenworkingwithpatientsonvision,itishelp-fultohaveavarietyoftasksthatcanbegradedintermsofcomplexity,size,anddistance.Thetasksselectedforthepatientshouldbeeasyenoughtoensure some success,but challengingenough topromote improvement.Once thepatientdemon-strates somepreliminary competencewith com-pensatory techniques, theactivitiesshouldbegintoreflectreal-lifetasksandsituationsthepatientwillencounterineverydaylife.

CLINICIAN TIP SHEET: DYNAVISION

General Information

AccordingtotheDynavision(WestChester,OH)Website:

Originallydesignedasadevicetoimprovethevisuomotorskillsofathletes,theDynavision™2000LightTrainingBoardhasbeenadaptedtoprovidethesametrainingbenefitstopersonswhosevisualandmotorfunctionhasbeencom-promisedbyinjuryordisease.Forpersonswithvisualandvisuomotorimpairmenttheapparatusisusedtotraincompensatorysearchstrategies,improveoculomotorskillssuchaslocaliza-tion,fixation,gazeshift,andtracking,increaseperipheralvisualawareness,visualattentionandanticipation,andimproveeye-handcoordina-tionandvisuomotorreactiontime.Forpersonswithmotorimpairmentitcanbeusedtoincrease

activeupperextremityrangeofmotionandcoor-dination,muscularandphysicalenduranceandimprovemotorplanning.Ithasbeensuccessfullyusedtoimprovefunctioninchildrenandadultswithlimitationsfromstroke,headinjury,ampu-tation,spinalcordinjury,andorthopedicinjury.Currentlythereareover400unitsinrehabilita-tionhospitalsacrosstheUnitedStates.52

Applicability to Service Members

AccordingtoMaryWarren:

Oneofthegreatadvantagesofthedevice[Dy-navision]asatoolspecificallyfortherehabili-tationofwoundedSoldiersisitscompetitivenature.Dynavisiondrillsarepresentedasgamesofskillbyinstructingthepersonstostrikeasmanylightedbuttonsaspossiblewithinthe

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andpushthebuttonbeforethenextonecomeson.

3. ModeC:visualtrackingtask.Asinglelight“moves”aroundtheedgesoftheringoflights,periodicallychangingdirection(thespeedofthebuttonschanginglightcanbeselectedat1secondorless).Thepatientvisuallytracksthelight.

4. ModeA,B,orCwithdigitalflashoption.Duringthetask(selectedbymode),dig-its(selectfrom1to7digitsatatime)areflashedonascreenateyeheight.Patientcallsoutthenumbersastheyareflashedwhileperformingtheothertasks(dividedattention).

Tasksmaybesetforadurationof30,60,or240secondsandmaybevariedbysizeandarea(eg,selectanyoneormorethefourquadrants,selecttheinner[threerings],middle[fourrings],orfull[fiverings]board).Taskresultscanbeprintedout(includingtotalhitsandreactiontime).

Reliability Studies

• Test-retestreliability:testedwithModeBusingtwoapparatus-pacedtasks.Moder-ate reliabilitywithcorrelationcoefficientrangingfrom0.71(for76subjects)to0.73(for 41 subjects) andpaired correlationcoefficientsrangingfrom–.75to0.93.57

• Test-retest reliability: tested reliabilityofthreetasksofdifficultygradedextremelyhigh(.88,.92,and.97).58

allottedtime.Thischallengestheclienttogivetheirbestefforteachtime.Thedevicerecordsandanalyzesperformanceshowingtheclientwheredeficienciesexisttoenabletheclienttoimproveperformanceontheboard.Clientscancomparetheirperformanceandcompetewitheachother.Becausethedevicewasdesignedforathletes,thelightscanbeprogrammedtomoveatveryhighspeedsanditisimpossibletobeattheboard,whichdrawsoutthecompetitivenatureofyoungmen.53

Dynavisionhasalsobeenusedinvisionrehabili-tationforindividualswithbraininjury(primarilystroke).54–56

Use and Options

Dynavisioncanbeusedformid-distancescan-ningskillsandisprogrammabletostartwitheasiertomorechallengingtasks.Thevisualimpairmentsitmaybeusedtoaddressincludesaccades,pur-suits,visualfielddeficits,andvisualneglectandinattention.

Dynavisionhasfourmodesofoperation: 1. ModeA: self-paced task.Onebuttonat

a timerandomly lightsupandstaysonuntil it ispushed.Patient tries to locateandpushthelit-upbuttonasquicklyaspossible.

2. ModeB:apparatuspaced.Abuttonwillrandomlylightupforaselectedperiodoftime(1secondorless)beforethenextlight comes on. Patient tries to locate

Selected References

KlavoraP,GaskovskiP,ForsythRD.Test-retestreliabilityoftheDynavisionapparatus.Percept Mot Skills. Aug1994;79(1Pt2):448–450.

KlavoraP,GaskovskiP,MartinK,etal.TheeffectsofDynavisionrehabilitationonbehind-the-wheeldrivingabilityandselectedpsychomotorabilitiesofpersonsafterstroke.Am J Occup Ther.Jun1995;49(6):534–542.

Traumatic Brain Injury Related Vision Issues: Hearing Before the Subcommittee on Oversight and Investigations of the Com-mittee on Veterans’ Affairs, Before the U.S. House of Representatives, 110thCong, SecondSession.ApplicationoftheDynavision2000toRehabilitationofSoldiersWithTraumaticBrainInjury.WrittentestimonyofMaryWarren.April2,2008.

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CLINICIAN TIP SHEET: PREREADING AND WRITING EXERCISES

lettersandnumbersandtoincreaseconfidenceinreadingabilitypriortoattemptingtoreadactualtext.Thepre-writingworksheetsconsistoftracingexercisestopromotereintegrationoftheeyedirectingthehandinmovement.

Theexercisescanbeincorporatedwithintreat-menttoimprovethevisualskillsneededforreadingperformanceandalsobeusedashome-worktosupplementtreatmentprograms.How-ever,noempiricalevidenceisavailableabouttheoutcomesassociatedwiththeseexercises.59

Use and Options

Theseexercisescanbeusedfornearscanning.Thefontsizeanddensityofthelettersvarytopro-videsimpletocomplextasks.Theexercisesareusedtoaddresssaccades,visualfielddeficits,andvisualneglectorinattention.Examplesoftheexercisesareavailableat:www.visabilities.com.

General Information

AccordingtoMaryWarren:

Theseexercisesconsistofreproduciblework-sheetactivitiesdesignedtoprovidepatientswithpracticemakingthepreciseeyemovementsneededtoaccuratelyidentifylettersandnum-bersandtowritelegiblyonline.Theexercisesareappropriateforpersonswithscotomas(ablindorpartiallyblindareainthevisualfield)secondarytoneurologicalimpairment(hemi-anopsia).

Thepre-readingdrillsconsistofletterandnumbercombinationsprintedinfourdifferentMunitsizestoaccommodateacuitiesrangingaslowas20/200.Theexercisesemphasizelettersandnumberswhichareeasilymisreadwhennotseenclearlysuchas,VandWand6and8.Theyareintendedtoincreaseaccuracyinidentifying

CLINICIAN TIP SHEET: NEURO VISION TECHNOLOGY SCANNING DEVICE

Neuro Vision Technology Scanning Device Use: Practice Option

Theexercisescanbeusedformid-distancescan-ningskills.Variousprogramsdifferincomplexity.Although research is currentlyunderway (emailcommunication,AllisonHayes,ManagerTrainingandResearch,NeuroVisionTechnologyPtyLtd,Torrensville,SouthAustralia,Australia,December16,2009),noempiricalevidenceiscurrentlyavail-ableabouttheoutcomesassociatedwiththeNVTScanningDevice.Thisdeviceandprogramweredeveloped for research. It addressesvisual fielddeficitsandvisualneglectandinattentionandisavailablethroughthedeveloper’swebsite(www.neurovisiontech.com.au).

General Information

Accordingtothemanufacturer’swebsite:

TheNVTVisionRehabilitationSystemaimstopromoteindependentlivingforpeoplewithaNeurologicalVisionImpairmentby:

• Assessmentofvisual andperceptualdeficitsthatimpactonactivitiesofdailyliving.

• Trainingincompensatoryscanningstrategies. • TransferofscanningskillstoMobilityinady-

namicenvironment.

ThisisauniqueprogramofinteresttoallstaffworkingintheareaofrehabilitationofAcquiredBrainInjury.60

CLINICIAN TIP SHEET: NEUROVISION REHABILITATOR

General Information

TheNVR is a computer-based, instrumentedvision therapy system thatusesWii (Nintendo,Kyoto,Japan)hardwaretoaddressdeficitsinvisualprocessing.61ThesystemincludesaBluetooth-inte-grated(Bluetooth,Kirkland,WA)balanceboard,aninfraredheadsensor,acontrollersensorreceiver,awirelessremotecontroller(“handshooter”),andNVRsoftware system.Additionally, a computer,projector,andscreenareneeded.

NVR Use: Practice Option

Usingremotesandsensors,theNVRprovidesinteractive,multisystemchallenge and feedbackthatintegratesvisionwithauditory,proprioceptive,balance,andvisuomotorcontrol.62Thereare fivesoftwaretreatmentmodules:(1)visualmotoren-hancer,(2)ocularvestibularintegrator,(3)dynamicocularmotorprocessing,(4)visuomotorintegrator,and(5)fixationanomalies.Allen Cohen, one of theNVR developers,

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information processing and stability of visualperformance.61NoempiricalevidenceiscurrentlyavailableabouttheoutcomesassociatedwiththeNVRandadultswithc/mTBI.Available through the developer ’swebsite

(www.nvrvision.com).

created three treatment protocols (which aredescribed in the operationsmanual). The firstphaseoftreatmentaimstoenhancethestabilityof the visual input system. The goal of phasetwo is todevelop fusional sustenance, and thegoalofphasethreeistodevelopspeedofvisual

Selected Reference

SuchoffIB.Newproductreview:theNeuro-VisionRehabilitator(NVR).J Behav Optom. 2011;22:13–15.

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Documents

Chapter 4 VISION ASSESSMENT AND INTERVENTION