1
Q
What are the foundational skills in Warren’s Hierarchy for Visual Perceptual Development?
A
oculomotor control: ability to move the eyes in tandem to produce single visual image (binocularity)
visual field: what you see without moving your head
visual acuity: sharp vision; function of fovea in retina
2
Q
Why is Warren’s Hierarchy useful?
A
It is a development framework for eval/tx of visual-perceptual deficits. Higher skills build on lower ones and are impacted by disruption of lower skills. Tx addresses lower skills to help restore higher ones.
3
Q
Diplopia:
A
- double vision, often due to problem w oculomotor function
- usually resolves on its own but improves faster w eye patch on weaker eye, and hemi-taped glasses
4
Q
What are the six extra ocular muscles and their functions on the eyeball (from neutral)?
A
- medial rectus - adduction
- lateral rectus - abduction
- superior rectus - elevation
- inferior rectus - depression
- superior oblique - intorsion (superior part of eyeball toward nose)
- inferior oblique - extorsion
5
Q
Visual acuity deficits:
A
- inability to focus image on retina (trauma)
- inability of retina to process image (disease)
- inability of optic nerve to transmit image (trauma, disease)
6
Q
►7 visual acuity interventions:
A
- increase: background contrast, lighting (2)
- reduce: background patterns, clutter (2)
- enlarge objects, organize materials, use community resources for compensatory strategies (3)
7
Q
Visual field deficits:
A
loss of vision in part of normal field of view:
- anopsias such as hemianopsias (most common w stroke) and quadrantanopsia
- scotoma (blind spot)
8
Q
What is hemianopsia?
A
a deficit in which each eye loses half its visual field
9
Q
Three types of hemianopsia:
A
Binasal: loss of nasal half of vision in both eyes
Bi temporal: loss of temporal half of vis. in both
Homonymous: loss of same half of each eye
10
Q
VFD cause and impact:
A
Cause: often stroke/tbi
Impact: client gets dependent on perceptual fill-in (AKA perceptual completion) so is unaware of what’s really there; visual search function slow and delayed; can produce anxiety
11
Q
►VFD intervention using mobility:
A
- help client increase distance, speed, frequency of head turning (for vis. search)
- organize the scanning strategy
- encourage detection of objects in the VFD
- encourage attention to objects
- practice shift of attention from central to peripheral fields, esp. in VFD area
12
Q
►scanning activities for mobility:
A
- “I see something (color)”; client has to find it
- “narrative walk” - describe what you see on client’s blind side
- mall walks
- hazard identification (steps, curbs, holes in the street, etc.)
- landmark identification
13
Q
►VFD intervention: reading
A
- pre-reading exercises to adapt saccade strategies
- practice reading w large-print text
- visual cues to identify L or R margin
- use of fingertip or pen to follow the line
- tracing the line
- practicing writing checks or addressing envelopes with new strategies
- increase lighting, contrast
- reduce patterns in background, clutter
- organize reading environment
14
Q
Unilateral neglect (UN):
A
- attentional disorder, often after stroke & on L
- reduced perception of stimuli contralateral to brain lesion
- associated neglect of limbs, sensory input
- high correlation w parietal lesions
- poor rehab outcomes
15
Q
effects of neglect
A
- asymmetrical visual search patterns
- client misses info on L side
- fixates on most peripheral vis. stimuli on R side
- client doesn’t re-scan independently
16
Q
UN severity level/ways of classifying:
A
- by what behavior is manifested: hemi-inattention, hemi-sensory inattention, visuo-spatial neglect, representational neglect
- by WHAT is being neglected: peri-personal inattention/neglect, peri-spatial inattention/neglect
17
Q
►behavioral indicators of neglect
A
- unsymmetrical weight-bearing
- difficulty initiating movement on L or turning to L
- bumping into things on L
- reduced L arm swing
- failure to check placement of limbs before transfer
- Pusher syndrome
18
Q
evaluating neglect:
A
Specialist needed for neuro-opthalmic evals, but these OT screens can determine referral needs:
- visual attention, field, acuity
- oculomotor control, ocular ROM
- fixation, vergence, alignment
- visual pursuit, tracking, saccades
19
Q
►Cancellation tests (to evaluate neglect)
A
multiple variations, including:
- star cancellation from multiple symbol chart
- double letter cancellation from random letters list (e.g. find all Es AND Rs)
- line bisection tests
20
Q
other ways to evaluate visual-perceptual problems:
A
drawing and copying designs such as flower, house, tree, clock
21
Q
►Interventions overview (for neglect):
A
- saccadic eye movement training
- neck muscle vibration (TENS)
- trunk rotation
- proprioceptive input
- optokinetic stimulation
- limb activation - visuo-motor cueing with tool use
- patching/occlusion
- prism use & adaptation
- scanning
- imagery (?)
- common visual and auditory spatial origination
- other assistive technologies
22
Q
saccades evaluation:
A
King-Devick test, in which pt. performs functional tasks dependent on visual-spatial organization
23
Q
training saccadic movement
A
- scan boards
- eye charts
- large-print shapes/letters on table or wall
- “follow the flashlight”
- your own ideas…
24
Q
trunk rotation:
A
Rotating trunk, head and neck to affected side reduces symptoms of neglect.
*Think of activities that produce trunk rotation in high- and low-tone situations.
25
proprioceptive input:
Grade input: gentle joint compression to supported wt. bearing on soft surfaces, then hard surfaces, then w/ weights/bands, etc.
\*Pay attention to painful shoulders!
26
limb activation:
* small, volitional movements w body part on L
* grade for + movement, concentration, volition
* consider "yoked" movement w functional use, where therapist wraps her LUE to client LUE
27
visuo-motor cueing and tool use:
* a form of limb activation
* evidence shows that adding object in affected extremity increases att'n to affected side
28
patching/occlusion:
* evidence shows patching unaffected hemi-field increases att'n to affected hemi-field
* partial lens occlusion in avail. field promotes scanning in affected field
29
►prism use:
* prisms found to be one of the most successful methods for reducing neglect
* prisms are prescribed by the optho or neuro-optho
* OT accompnay client to optho/neuro-optho eval when possible
* conduct activities with prisms
* caution: mobility, transfers, standing
30
visual scanning training (VST):
beneficial in short run for reducing neglect but effects don't last; combine w/ other interventions
31
scanning strategies:
* lighthouse strategy
* Dynavision 2000
* neuro-vision technology (effectiveness still in question)
* also: anchoring, border scan, perimeter scan, visual sweep (L to R)
32
imagery:
* imagined limb activation shown to reduce symptoms of neglect
* challenge: create imagined limb activation (could imagine activities using both sides of body, i.e. swimming, playing piano, etc.)
33
common visual and auditory spatial origination:
* music/object on affected side to increase att'n
* therapist stand and talk in pt.'s affected field (for mild neglect)
34
►other treatment considerations for hemi-inattention:
* interaction with the target once located
* conscious attention to visual detail, careful exploration of the object
* practice of search strategies in context: Recheck work
* **client and family education**
35
►What is the difference between hemianopsia and hemi-inattention?
**Hemianopsia (VFD):**
* a sensory deficit, lower on Warren's hierarchy
* with help, client will compensate by using visual attention
* eye movement directed to L side
* less effect on task performance
**Hemi-inattention:**
* a "consciousness" deficit, higher on Warren's hierarchy
* no attentional mechanisms engaged
* little to no eye or head movement to left to search visual field
* more severe effect on task performance
36
Will a problem with eye tracking be problematic for pattern recognition? Why or why not?
Yes. Tracking is lower on Warren’s hierarchy, and higher visual-perceptual skills (like pattern recognition) depend upon it.
37
Name 3 interventions you should always consider for any vision-related problem
INCREASE: lighting, contrast and size (magnification)
38
Why is use of mirrors a questionable intervention for addressing hemi-inattention?
Hemi-inattention is not just a visual problem, but a visual-perceptual one. It is hard for those with hemi-inattention to understand what is happening with the mirror, and therefore it isn't always effective. (remember video of doc. trying it with pt)
39
Self-management for low vision (or any long term disorder) IS:
1. an individual's ability to manage:
* symptoms
* treatment
* physical, psychosocial, and lifestyle changes
... related to living with their disorder.
2. an individual's engagement in:
* health-promoting activities
* monitoring/managing symptoms
* managing related functional, emotional, and interpersonal impacts
* adherence to tx regime
40
Self-management for low vision (or any long term disorder) IS NOT:
* self-helps groups
* elimination of need to healthcare pro's
* group therapy
41
Self-management enables:
* making informed choices
* applying general skills to specific problems
* collaborating with healthcare pro's/systems
* practicing new health perspectives/behaviors
* regaining/maintaining emotional health
42
Self-management is grounded in social science theory:
1. **Transtheoretical Model** (Stages of Change: precontemplation, contemplation, prep., action, maintenance, relapse)
2. **Social Learning Theory**: Self-efficacy results as confidence and belief in ability to execute an action or thought process leads to personal mastery.
3. Also CBT
43
3 skillsets that lead to good self-management:
* skills to deal w/ chronic illness
* skills to continue normal lifestyle
* skills to deal w/ emotions
44
5 core skills to develop for self-management:
1. problem-solving
2. decision-making
3. resource-utilization
4. paretnering w health pro's (MD/ nurse, OT/PT, counselor/psych)
5. taking action
45
CDSMP is:
Chronic Disease Self-Management Programs
46
CDSMP guides the mastery of skills via:
* action-planning
* feedback on progress
* modeling self-management behaviors
* modeling problem-solving strategies
* social persuasion through group support
* individualized guidance
47
How can occupation be used to refocus self-management?
A client-centered, occupation-focused approach to self-management emphasizes lifestyle and emotion-based skills.
48
CDSMP outcomes:
* improved health status, slowing of decline
* positive health behaviors, improved self-efficacy
* better utilization of health services (fewer ER and doctor visits)
* improved quality of life
49
Evidence for CDSMP:
It is used internationally and for several decades. Effectiveness has been demonstrated for:
* diabetes
* arthritis
* chronic pain
* heart and lung disease
* stroke
* low vision
50
What does this describe, visual history or peripheral field?
Find out if there is PMH of visual deficits; Refer pt to vision specialist if anything is odd in screening; If you can, accompany pt to ophthalmology or neuro-ophthalmology eval (if you can't, read the report and call specialist to get details); begin functional application of visual evaluation
Visual History
51
What screening does this describe: central field/central fixation or peripheral field?
Hold object about 16 inches from person's face at midline and about nose level; observe pupils to determine whether both are fixed on the object; move the object within the central 30 degrees of the visual field; note if person turns his/her head to look
Central field/central fixation
52
What screening does this describe: depth perception or peripheral field?
hold the object outside the peripheral visual field in superior fields (at 11 o'clock and 1 o'clock), horizontally (at 3 o'clock and 9 o'clock), and inferiorly (at 5 o'clock and 7 o'clock); instruct person to say when they see the object
peripheral field
53
What screening does this describe: oculomotor ROM or double simultaneous stimulation?
this is only done on a pt with a normal field of vision to evaluate **unilateral inattention**; move two objects, one in each hand alone or together (i.e. R, L, or BOTH in random order); if inattention exists, the person will not detect BOTH movements and will reply R instead
double simultaneous stimulation
54
What screening does this describe: oculomotor ROM or depth perception?
have pt cover his/her R eye with the R hand, then the L eye with the L hand, then do the activity with both eyes uncovered. Move the object in an H pattern; observe for full ROM of the pupils
oculomotor ROM
55
Is the screening for double simultaneous stimulation done on a person with a normal field of vision? Yes or No
Yes - only done on a person with a normal field of vision
56
What screening does this describe: peripheral field or depth perception?
hold one pencial about 16 inches in front of pt; occlude the R eye with the R hand; have pt take a pencil in the L hand, bring it over the head, and touch it to the tip of your pencil; repeat L eye occluded with L hand; note if there is an obvious deviation of pupils from the center.
Depth perception
57
LVSM (P):
Low Vision Self Management (Program)
58
What does this describe?
Problems discriminating hues; pt must discriminate between color perception and color agnosia, so do a screening that does not NAME colors, but SORTS them; problems indicate possible visual organization problems and/or color blindness
Color Perception
59
True or False: color is an important influence on quick perceptual procesing
True
60
True or False: the King-Devick Test of Visual Scanning involves a functional task that does not need visual-spatial organization to perform
False - you DO need visual-spatial organization to perform this!
61
What is LVSM?
A group intervention for low vision, focusing on psychological issues. It was developed into its current 10-session form over about 10 years.
62
What is the primary theoretical focus of LVSM?
CBT (cognitive-behavioral therapy)
63
What methods do LVSM groups use?
* educational presentations/materials
* problem-solving
* CBT skills training
* exercise
64
LVSM results:
* significant change in negative affect
* increased self-efficacy
* improved function and quality of life
* inprovement in knowledge, skills and problem-solving
* improved sense of security in daily occupations
* improvement sustained 28 months later
65
Obstacles to LVSM (and any program):
* transportation/attendance
* number of sessions needed to address needs
* participant recruitment
* hard to get people to attend ALL the sessions
* hard to get new program off the ground
66
"LVSMP: A 10-session program" does the following:
* acknowledges vision impairment as a chronic, progressive condition
* addresses general self-management for chronic condition
* focuses on specific low vision issues
* is intended as a group intervention but can be used with individuals who are uncertain a) about attending 10 sessions or b) about reimbursement for the group
67
All 10 LVSMP sessions contain:
1. welcome and intro
2. follow-up from last session
3. info and resource sharing (peer or professional)
4. problem-solving discussion and/or modeling activity
5. "take action" project in home or community
68
Outcomes: conditions and measures
* mood: Profile of Mood States (POMS)
* clinical depression: Center for Epidemiological Studies Depression Scale (CES-D)
* visual function: Melbourne Low Vision ADL Index (MLVAI)
* participation: Activities Card Sort
* self-efficacy: Low Vision Self-Efficacy Scale (LV-SES)
69
LVSMP sessions
1. Understanding Vision Loss
2. Coping with Vision Loss
3. Using Available Vision and Using Other Senses
4. Communication
5. Personal Care
6. Household Management
7. Getting Around
8. Leisure and Recreation
9. Advocacy
10. Your Family and Friends
70
Good LVSMP takeaway:
From Session 3, Using Available Vision:
**The Four B's**:
* Bigger
* Brighter
* Bolder
* Be Organized
71
"Take home messages" re: LVSMP:
* Self-management works well for the low vision population with **acquired eye disease** or **neurovisual deficits** (with minimal cognitive impairment)
* Sessions can be group or individual
* You can customize interventions for client-centeredness
72
Two intervention areas to emphasize:
* work with ADLs that are reading and "way-finding" dependent
* work with envoronmental adaptation with attention to **lighting**, **magnification** and **contrast**.
73
►Warren's Heirarchy:
foundational skills: oculomotor control, visual fields, visual acuity
1st level: Attention: alert and attending
2nd level: scanning
3rd level: pattern recognition
4th level: visual memory
5th level: visuocognition
6th level: adaptation through vision
74
other suggestions for hemi-inattention:
* reduce background patterns
* proper lighting of room and task
* increased contrast
* many of the interventions for acquired eye disease can work for clients w neurogenic visual problems, depending on the severity
75
Adults Spring 2015
flashcards
Decks in class (5)
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