Test 2 Neurorehab

warren visual perception hierarchy:

◦Each skill level depends on the integration of the levels below it

◦Disruption of one skill level will affect the levels above it

◦Evaluation process begins by assessing the foundation skills (VF, VA, O-M control)

visual field is:

Visual world that can be see when looking straight ahead

normal visual field in degrees

◦60 degrees superiorly
◦75 degrees inferiorly
◦60 degree nasally
◦100 degrees temporally

what is the most common visual impairment after CVA

visual field deficit

visual field testing

perimetry testing

3 components of Visual field

◦Sustained fixation on a central target

◦then bring in second target of a specified size/brightness in a designated area of the field

◦see the second target without breaking fixation on the central target

what must the patient have to do perimetry / visual field testing?

sustained attention

types of perimetry tests

bowl perimetry and goldman manual bowl

OT standardized tests for central visual field

Kinetic 2 person

Confrontation Test
SK Read

Additional OT VF tests, clinical observations

OT standardized tests extra personal space

Dynavisiom

Scan Course

visual field test interpretation: gray scale diagram

-Sensitivity of field is described using different shades of gray

-Light shading=high threshold, can detect small target

-lack shading=no response to target

OT visual field testing: kinetic two person confrontation test

Occlude one eye, glasses off

◦Can do w/ B eyes open for functional perspective

-Dim the lights
-Use penlight + 2nd target held at 1 m. distance from client

-2 examiners:
◦Front examiner (is often a family member!) - holds target, ensures ct's eyes are front and center

◦Rear examiner - moves penlight and notes when observed by ct.

Kinetic Two Person Confrontation Test

-Slowly present target at 3, 9, 12 and 6 o'clock in an arc-like motion

-Client indicates where 1st sees penlight

-Front examiner continues to observe client's eye

-Repeat with other eye

VF assessment results:Share info w/ client to build insight/awareness

-Discuss assessment results

-Demonstrate their "wedge of vision"

◦Compare affected vs intact VF

◦Walk up along side of them, so they can see the point at which they can see you

◦Use client's arms to demonstrate "wedge of vision"

◦Demonstrate in functional context

-May need to re-visit periodically to increase awareness

Additional OT VF Evaluations: Clinical Observations & Task Analysis

4 primary barriers

◦Search pattern restricted to midline and sound side

◦Slowly scans toward deficit side

◦Misses or mis-identifies visual details on deficit side

◦Decreased ability to monitor hand during activity

Additional OT VF Evaluations: Clinical Observations & Task Analysis

search pattern restricted to midline and sound side:

Due in part to perceptual completion - ct. completes scene based on what is expected to be there

Distrust of deficit side

Leads to collisions, disorientation, unable to find needed items

Additional OT VF Evaluations: Clinical Observations & Task Analysis

slowly scans toward deficit side

No distinct boundary between sound and deficit side; limited sense of how far to look
Impacts efficiency, timeliness and safety

◦Misses visual details on deficit side:

Occurs if VF cut impinges on fovea, then macular scotoma

Impairs reading, may cause incomplete & inaccurate task performance

◦Decreased ability to monitor hand during activity

Occurs if VFD is on same side as dominant hand AND VFD affects fovea/macula.

what are effective search patterns in the visual field

linear strategy for lines of things (think soup cans)

or circular pattern for scanning a messy desk

Characteristics of effective search pattern

◦Symmetrical
◦Predictable
◦Thorough and comprehensive
◦Resilient (Consistent accuracy even when task becomes more complex)

characteristics of ineffective search pattern

◦Abbreviated, incomplete search toward affected side

◦Asymmetric

◦Random

◦Inconsistently accurate in ID of target

◦Ability to search decreases with complex patterns

if macula is affected what should you evaluate in visual field

evaluate central visual field or personal space

◦Example:
Single letter cancellation test (biVABA)
Have ct. perform, observe search and scan patterns, provide feedback, repeat test and see if the ct. improves

Visual field Impact on reading

Makes errors reading text on reading acuity cards

Omits larger optotypes on affected side on intermediate distance acuity test

Reads more accurately as optotypes (letters on eye chart) decrease in size

Reading assessment: MNRead

purpose:

assess how reading performance depends on print size

MNRead 3 measures of reading performance

◦Reading acuity

◦Maximum reading speed

◦Critical print size

◦Reading Accessibility Index: individual's access to text across range of print sizes found in everyday life

MNRead application

◦prescribing optical corrections for reading & other near tasks

◦low vision assessment e.g. impact of scotoma on reading

◦prescribing magnifiers, other reading aids

◦special education, research

OT assessments of visual field deficit - Dynavision (extra personal space)

Used to train search strategies and improve ocular-motor skills

Looking for initiation of scanning to blind field first

Head turning to view periphery of board

Efficient circular search patterns

Equal attendance to L and R sides of the board

Can vary level of challenge and task

Light on until touched

Light on for pre-determined time, then changes

Flash option: requires ct. to shift attention

Bioness Integrated Therapy System (BITS) - for visual field

- touch screen board you used at FW1 (person can stand etc.

Visual field deficit assessment - extra personal space

Scan course

◦Combines visual search w/ ambulation

evaluating extra-personal space visual field deficit additional obersvations of client in dynamic environment:

(what to look for)

Hesitant, uncomfortable and anxious

Uses trailing technique or attempts to follow you

Comes very close to obstacles on blind side

Uncertain in responding to subtle features (curbs, support surface changes)

Stopping to search - may be unable to combine visual search with ambulation

Appears to be lost OR complains of disorientation

sharing the info of visual field assessment results w the client:

Ask client how they think they did with this portion of the testing

Point out errors as well as what they did correctly

If scanning speed is an issue, consider demo'ingtypical speed

Tie in with impact on daily activities

Reinforce as needed

visual attention requires the ability to

◦closely observe objects to gather info about features and relationship to environment

◦ignore irrelevant sensory input

◦Sustain focus for length of time

Shift focus in organized, efficient manner

visual attention is a critical pre req to

learning

what is visual attention expressed through

visual search and scanning

Left hemisphere:

◦Directs visual attention towards right half of visual field only

left hemisphere lesion

decreases attention to R, limits processing of details & item by item search, but have back up

right hemisphere

◦Directs visual attention towards both right AND left halves of visual field

right hemisphere lesion

decreases ability to direct visual search to L + decreases global attention
to R OR may over attend to R

spatial neglect occurs with

with R CVA or possibly bilateral lesion

with range of severity (mild to severe)

Can occur with VFD (hemianopsia)

other features of spatial neglect

◦Will not initiate scanning to L, may not cross midline

◦Asymmetric, incomplete search pattern confined to R

◦Will not re-scan, difficulty picking up on environmental cues

◦Cognitive component; may not be able to see LVF info when pointed out.

spatial neglect - common tests

Line bi-section

Line crossing

Letter cancellation

Mesulam

Design copy

biVABA visual search tests for spatial neglect

No cut off scores, observational,

Provides info re: visual search pattern via task analysis

7 visual search sub-tests of increasing complexity (single letter search, word search, circles, etc)

biVABA Visual Search Tests: Interpretation

-Inattention may be most apparent when pattern is complex and unstructured

-Results of visual search sub-tests include

◦Description of search pattern

◦Completion time

◦# of errors

-Place paper in midline, but ct. can re-position

-Verbal and physical cueing is important

◦Assists w/ determining rehab potential

◦Ability to use cues is considered a strength; will allow ct. to learn to compensate

biVABA Visual Search Tests: Interpretation

4 typical search patterns

horizontal left to right

horizontal rectilinear (like mowing a lawn)

vertical rectilinear

vertical left to right

functional test: (for neglect)

}Kessler Foundation - Neglect Assessment Process (KF-NAP)

-Looks at neglect during functional ADL activities

-Administered in a variety of settings (home, hospital room, clinic in functional spaces)

-Utilize their own items (grooming, clothing, WC etc)

-Designed for brain injury and stroke, brain surgery

-Takes into account the personal space, peri-personal space, and extra personal space in a way that pen and paper tasks do not

Kessler Foundation - Neglect Assessment Process (KF-NAP) 4 point scale

0 = No neglect observed

• 1 = Mild neglect observed. Pt always explores right hemi space first, then slowly to left. Omissions/collisions are rare and inconsistent. Fluctuations may be noted with fatigue.

• 2 = Moderate neglect observed. Clear and consistent omission/collisions to left. Pt able to cross midline, but task performance to left is incomplete and ineffective.

• 3 = Severe neglect observed. Patient is only able to explore right hemi-space and is not able to cross midline to perform task.

• If an item is impossible to score, it is not included in the total.

• Scoring =total (sum) of scores divided by number of scores, multiplied by 10 (to give score ranging from 0-30)

KF-NAP Subtasks

1.Gaze Orientation
2.Limb Awareness
3.Auditory Attention
4.Personal Belongings
5.Dressing
6.Grooming
7.Navigation
8.Collisions
9.Meals
10.Cleaning after Meal

Characteristics of
Visual Field Deficit

-Abbreviates search towards blind side
◦Results in omissions on affected side

-Search can be slow

-Search pattern is organized

-Person checks work for errors

-Person maintains attention throughout test

-Person benefits from cueing

characteristics of hemi-attention / neglect

-Abbreviates search toward blind side

-May work quickly

-Search pattern disorganized

-Less likely to check for errors

-May lose attention to task

-Less likely to benefit from cueing

Client has significant left VFD that split the fovea. - what their test would look like

•Initiated visual search towards the middle of the page, unaware that there were figures to the left.

• Demonstrated very slow but organized left to right linear search.

• She checked her work.
Total test time: 8 minAccuracy:66%

Ct. w/ hemi-inattention/neglect compounded by left VFD.

-Initiated visual search from the right and randomly
crossed out targets on the right, occasionally getting a target on the left.

-Ct. did not check his work.

-Total test time: 43 sec. Accuracy: 78%

}You are working with a client who is completing the letter cancellation subtest of the biVABA and observe the following:
◦Disorganized visual search pattern
◦Client works quickly and does not check for errors
◦Client requires re-direction to task x2
◦Client did not appear to benefit from cueing after initial attempt


What impairment do you suspect?
A.Visual field deficit
B.Hemi-inattention
C.Macular degeneration
D.Glaucoma

B.Hemi-inattention

Intervention for VFD - Evidence

-Minimal evidence that VF can be restored

-Techniques directed at compensation of VF

Visual field deficit compensatory approaches

use eye & head movement to scan, search, and broaden VF

Client needs to develop insight that they are NOT seeing all there is to see on affected side

Intervention for visual field deficit:

Education critical
◦Ct. must believe they cannot trust visual information on blind side
◦Allows for intellectual override

General ADL - increase visibility, simplify, organize, use of scanning routes to locate items

Mobility

intervention for visual field mobility:

◦Goals: increased # and speed of head movement + wider head turns toward blind side, increased anticipation, improve organization of search, increase attn to detail

◦Methods: DynaVision, narrated walks, "Find red", scanning routes (zigzag, Lighthouse, sweep eyes down & up), prisms

◦For less active clients: scan boards, cards

Interventions for visual field

-scanning routes strategies

scanning strategy training for searching for needed items when stationary items used

Can begin w use of simple materials
◦playing cards
◦Post it notes

Then transition to use in context of daily activities

ex: ingredients in cabinet, scavenger hunt etc.

interventions for visual field deficit scanning routes while moving

Lighthouse Scanning Strategy
Turn your head to the right and left to survey what is in front of you and to the sides. (Similar to how a lighthouse scans the ocean.)

Sweep your eyes down and up to see obstacles at feet and eye level.

intervention visual field deficit reading treatment progression

Pre-reading exercises

Column text (table of contents, menu, then newspaper)

Continuous text
Large print
Standard

◦Single lens v. bifocal
(Avoid bifocal lens)

◦Anchoring line

intervention for visual field defect handwriting

◦Slow down, monitor pen tip

◦Tracing exercises

◦Practice on forms, large print checks

◦Use bold line paper,
marker or 20/20 pen

spatial neglect intervention goals

◦Increase awareness
Increase efficiency and consistency of visual search pattern

3 approaches for spatial neglect intervention

◦Client centered
◦Environment centered
◦Prism adaptation

spatial neglect intervention: client centered

◦1st step
Insure visual input is optimal (correct diplopia, lighting, contrast)

◦Teach client 2 search strategies
Structured linear pattern = L to R
Unstructured/landscapes = circular L to R

◦Emphasis
Initiate search from the L

Execute complete search pattern

Observe all visual details

Anticipate visual input from the L

Rapidly divide and shift attention

Sustain attention in dynamic environment

additional components for spatial neglect intervention

◦Address insight; ask what strategies they plan to use, post performance analysis, develop new plan, will require more reinforcement than for person with VF loss alone

◦Activity should be as interactive as possible AND include motor input

◦Broaden VF needed to complete the activity as much as possible ie. DynaVision

◦Emphasize careful inspection of detail i.e. matching activity, Solitaire

◦Can try occlusion of R VF and anchoring line if hypo-attentive to L

◦Severe neglect; incorporate wt. shift & joint compression along with looking to the left

Spatial neglect: Environment Centered Intervention

-May be ONLY approach for person with lack of insight and severe neglect

Emphasis:
◦Decrease background pattern by elimination and enlargement
◦Increase lighting
◦Add contrast

Prism adaptation intervention for spatial neglect

◦Wedge shaped lens; is ground into the lens or applied temporarily (Fresnel prism lens)

◦Purpose: Bends light entering eye, allowing image from each eye to converge
Displaces the image to the right or left

◦Also used for strabismus

◦Recommended by eye care specialist

◦OT role: incorporate use into
daily routine, promote compliance

spatial neglect intervention other teqniques

◦Auditory matching
◦Trunk rotation
◦Saccadic training
◦Imagery
◦Eye patching

Lack of Ocular Alignment = Strabismus

causes

◦stroke, brain injury

Esotropia

eye deviated inward

Exotropia

eye deviated outward

Hypotropia

eye deviated downward

Hypertropia

eye deviated upward

Diplopia

Double vision

Causes: CVA (brainstem), aneurysm, brain tumor

Diplopia - OT role/intervention

occlusion - stops double vision

Total:
◦Compliance poor, impacts balance & mobility, discomfort

or

Partial:
◦Better compliance, use opaque surgical tape
◦Placement; round piece in line of site OR nasal portion of non-dominant eye

Occupational Therapy Evaluation for Neurodegenerative Diseases

Occupational profile

history of disease

Valued roles and occupations

Screens for specific concerns or problems

must be sensitive to neurodegenerative client's

changing function

fear of the unknown

problem areas that may not be spontaneously discussed such as fatigue, depression, sexual function, and cognitive concerns that impact their occupations and social network.

goal setting for neurodegenerative diseases

goal: reduce the effects of disability resulting from disease impairments and to maintain or promote independence and quality of life.

Given the progressive nature of many neurodegenerative diseases, regular reassessment and reordering of goals and priorities may be necessary.

not everyone goes to therapy straight through - some go once every 6 months as a "check up"

treatment strategies for self enhancement roles (Neurodegenerative diseases

-Maintaining leisure pursuits may be a high priority, but they are often the first roles to be abandoned.

-we can help to modify activities and provide proper equipment to allow clients with neurodegenerative diseases to continue with leisure pursuits.

Analysis of Occupational Performance Specific to MS (assessments

-Canadian Occupational Performance Measure (COPM)

-Modified Fatigue Impact Scale to screen for fatigue severity

-6-Minute Walk Test to assess endurance and fatigue

-Sleep history questionnaire or diary

-Home assessment

-Beck Depression Inventory-Fast Screen to assess depression

-PBT to measure functionalcognition(MPT, WCPA, EFPT, CTPA,etc)

•Berg Balance Scale

•ADL, IADL, and dysphagia assessments

•Nine-Hole Peg Test or Purdue Pegboard to assess dexterity

•Semmes-Weinstein Monofilaments to test sensation

•Manual muscle testing (MMT), ROM testing, and grip strength (dynamometry)

Vestibular evaluation

what is a huge restriction for clients with ALS

participation restrictions (as a result of factors directly impacted by ALS)

Limiting Client factors ALS

•Dysarthria (difficulty speaking)

•Functional Mobility

•Fatigue

•Helplessness

•Rate of Progression (varies greatly)

•Cognition

assessment in ALS:

ALS Specific Quality of Life-Short form - 6 domains:

Focuses on six domains:

•Negative emotion

•Interaction with people and the environment

•Intimacy

•Religion

•Physical symptoms

Bulbar function (eating, speech, swallow skills)

bulbar onset ALS

muscles used for eating, swallowing, speaking are impacted first

limb onset ALS

limb function is impacted first

Activity Card Sort - ALS

what setting?

•Includes 89 cards with photos of activities and occupations

•IADLs

•Low demand Leisure

•High demand Leisure

•Social

•Patient will sort the cards according to their participation

•Measures % of participation

**not appropriate in acute care, better for outpatient**

other measures to assess functional mobility ALS

Timed 10 M Walk Test

5x Sit to Stand

Dynamic Balance

Functional Reach

berg balance scale

range of motion assessments ALS

cervical ROM

Upper Extremity ROM

Lower extremity ROM

strength testing ALS

Upper Extremity MMT

Lower Extremity MMT

Hand Grip Dynamometry

types of therapeutic intervention for ALS

•Task simplification

•Maintenance exercise

•Energy management

• Adaptive equipment & DME

•Social & cognitive strategies

•Multidisciplinary Care

Goal setting during early stages: ALS

Manage energy

Optimize/maintain strength and range of motion using home exercise programs

Compensate for initial hand/foot/head weakness

**Moderate intensity exercise is safe and indicated in ALS**

energy management goal for ALS

decrease fatigue and enable participation in daily tasks and activities

energy management ALS

•Fatigue is a very common symptom

•Perhaps most noticeable in early stages

•Aim is to establish an appropriate balance between activity and restorative rest

physical activity in ALS intensity of exercise

MODERATE

do not do more as it could lead to quicker progression of disease.

sample exercise protocols for ALS

recumbent stepping

dynamic cycling (30 min session with 5 minutes of rest)

daily home exercise program of stretching and resistance exercise

moderate walk on treadmill x2 per week

low load prolonged strength ALS

proven effective to prevent risk of developing deformities / contractures in UE

team gleason (ALS) - grant program

•Technology and equipment

•Home automation: light switches, thermostats, garage door openers, deadbolts, outlet control

•Seat elevator grants

•Voice and message banking
•Care services
•Virtual community gatherings
•Grants for respite care in select states
Adventure

goal setting during mid stage ALS

•Adapt participation in ADL and IADL through AD and DME (delegate)

•Stabilize joints as function is lost or weakened

•Energy management

•Adjust exercise programs

•Equipment for functional mobility (prepare for a power wheelchair)

goal setting ALS later stages

•Focus on enabling the caregiver to assist

•Optimize safety, positioning, safe transfers

•Employ/refine AAC equipment

•Consider touch screen and motion tracking

•Assess and manage dysphagia

•Environmental modifications

•Optimize social & leisure participation

•Smart phone

•Electronic control unit (ECU) /smart home