2/22/2016

VISUAL DEFICITS FOLLOWING STROKE: OUTLINE

 Why is vision important? DO YOU SEE WHAT I SEE?  Common visual disturbances following stroke VISUAL DISTURBANCES FOLLOWING STROKE  Homonymous Hemianopsia  Assessment  Strategies/treatment ACUTE STROKE BEST PRACTICES WORKSHOP  Unilateral Spatial Neglect “ADVANCING BEST PRACTICES IN ACUTE STROKE CARE” FEBRUARY 23, 2016  Safe Mobility in Patients with visual disturbances and/or neglect following stroke  The “How to”: Basic visual field confrontation Laura Swancar O.T. Reg (Ont.) testing in acute stroke Stroke Occupational Therapist

VISION IS IMPORTANT BECAUSE…. WHY IS VISION IMPORTANT?

A. It is our most far  Vision is our most far reaching sense reaching sense.  Provides speed and instant identification of B. Related closely to objects and situations balance, safety and  Vision and mobility, balance, safety fall prevention.  Important part of motor and postural control C. Important for (closed eyes item on Berg balance test) motor and postural  Vision and the older patient control. D. A key part of all our daily life activities. E. All of the above.

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VISUAL PERCEPTUAL HIERARCHY ADAPTATION THROUGH VISION

Adaptation through Visual Cognition

Visual Memory

Pattern Recognition Scanning Attention = Alert and Attending

Visual Acuity, Visual field, Occulomotor Control

Warren, 1993

THREE COMPONENT MODEL OF VISION

VISUAL DEFICITS AND DAILY LIFE MITCHELL SCHEIMAN, OD, FCOVD Visual Integrity  How does the disability affect a person’s DAILY Visual acuity ACTIVITIES, WORK, LIFE ROLES? Refraction Eye Health  Self care – washing, dressing, toileting, grooming Visual Fields  Home and community management – driving, reading, cooking, finances  Return to work  Mobility – safety Visual Visual Efficiency Information Processing Accomodation Visual spatial skills Binocular vision Visual Analysis skills Eye Movements Visual motor integration skills

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VISUAL PROCESSING

HOMONYMOUS HEMIANOPSIA HOMONYMOUS HEMIANOPSIA IS…..

A. A special type of  Also called Visual Field deficit organic milk.  Blindness in ½ visual field of each eye B. A condition affecting  Quadrantanopsia – ¼ visual field of each eye half the population. C. Blindness in half the vision in both eyes. D. A visual field deficit. E. C and D. F. A and C.

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BEHAVIOURAL CHANGES IN VISUAL FIELD DEFICIT: HOMONYMOUS HEMIANOPSIA DAILY LIVING CHALLENGES

 Adopt a narrow search pattern confined to  Driving midline and sound side  Shopping and community events  Person scans very slowly towards deficit side  Yard Work  Missing and /or “misidentifying” visual detail on  Meal preparation the “blind” side  Financial management  Reduced visual monitoring of the hand  Functional communication  May feel unsafe due to loss of peripheral vision  Housekeeping  Decreased engagement, withdraws socially  Self care - grooming

HOMONYMOUS HEMIANOPSIA BEST STRATEGY - EDUCATION MORE STRATEGIES

 Compensation requires conscious cognitive strategy – increase visual search strategies. Provide an anchor on the affected side  Must believe vision cannot be trusted on deficit side. Ensure important items are in their intact visual  Awareness allows client to develop “intellectual field over-ride”. Encourage pacing to scan slowly  Develop awareness through practice.  Use low vision devices like magnifying lenses  Ensure adequate lighting  Watch for glare Increase visual contrasts

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VISUAL INATTENTION OR VISUAL INATTENTION OR UNILATERAL SPATIAL NEGLECT UNILATERAL SPATIAL NEGLECT

 Inability to attend or respond to stimuli presented opposite to the side of the brain lesion

 Inattention/neglect of the one side of the body or the person’s environment  Left neglect more common but Right sided neglect possible

UNILATERAL SPATIAL NEGLECT - UNILATERAL SPATIAL NEGLECT COMMON BEHAVIOURS

 Associated with lower functional recovery and  Body (personal neglect) decreased level of independence.  Leaves arm hanging at side of chair  Significant implications for safety and falls.  Shaves only right side of face  Within reaching space (peripersonal space) Main therapy and education goal:  Eats food only from right side of tray  Environment (extrapersonal space) Increase awareness of neglected side.  Bumps into things on the left  Doesn’t attend to visitors sitting on left side of bed/room

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NEGLECT/INATTENTION STRATEGIES FOR VISUAL OR BODY NEGLECT STRATEGIES CONTINUED

 Ensure essential items, such as call bell, urinal, telephone are on good/intact side so  Position neglected arm in midline position that they are accessible if needed within visual field  Use a reference point or anchor  Approach the person on their best side (ie on left side from Right if left inattention)  Help family to learn strategies by respectful modeling and positive reinforcement  Speak to person midline with eye contact –  Encourage client to wash neglected side move to left side if possible

UNILATERAL SPATIAL NEGLECT: VISUAL INATTENTION OR NEGLECT VERSUS STRATEGIES SUMMARY VISUAL FIELD DEFICIT:CONTINUUM

Functional Category Observed Behaviour Strategies Mobility  Bumps into things/walls/people on the -Supervision, frequent checks for needs  Walking left -Transfer belt, transfer to unaffected side  Wheelchair  FALLS, numerous close calls -Instructions to good side, eye contact  transfers  Misses target in pivot transfers -Bed alarm -grab bars for toilet/arm rests for chairs

ADL’s  Shave ½ face, eat ½ tray, wash ½ body -Position necessary items on good side  washing  Clumsy/knocks over items -Cues, reminder to wash left side  eating  Misses important steps in tasks -Use anchor on left ie tea cup, red band, cell  toileting  Forgets to dress left side phone Visual Field  grooming -Set up an organized and predictable Visual neglect with no  dressing environment .….continuum…… Deficit with -Dress affected side first, undress good side awareness first full awareness Social Interactions  Ignores visitors/family -Help family to understand, teach strategies  Tires easily -Encourage breaks/rest for client  Orients body and attention to right side Cognition/Thinking skills  May have difficulty learning new skills -Important info to good side  Poor insight and safety judgement -Respectful Repetition  Difficulty reading -Supervision!  Inefficient visual scanning pattern -Pay attention to level of cognitive FATIGUE during activities ie ambulation -Shorter sessions with frequent rests/breaks  Rushes to complete tasks, no rechecks

6 2/22/2016

SAFE MOBILITY IN PATIENTS Balance problems + WITH HOMONYMOUS HEMIANOSPIA visual deficits = high risk for FALLS Fiona Maclean, Physiotherapist, Regional Stroke Unit (RSU)

PATIENTS WITH VISUAL FIELD DEFICIT MAY: ALL STROKE PATIENTS SHOULD BE CONSIDERED AT RISK OF FALLING  Collide into their surroundings on one side (usually left) with walker or with their body  Presence of Unilateral Spatial Neglect has been  Fall if they run into objects or people, or trip over strongly associated with increased risk of injury and items. with poor functional outcomes  Most patients also have weakness and reduced  Patient’s have reduced ability to learn to compensate balance which makes it harder to regain balance due to the stroke, therefore repeated cuing and if they do bump into objects. supervision is required

7 2/22/2016

HOW YOU CAN HELP WHEN WALKING WITH PATIENT FALL PREVENTION

 Ensure both hands are on walker, may need to  Stress importance of safety and calling for help to assist hand to stay on walker get out of bed (have call bell within visual field)  Stand on the patients’ affected side  Bed alarms on, bed in lowest position  Provide cueing – verbal, tactile to assist patient  Attach call bell to pts. gown if you think they are to attend to affected side likely to get up on their own  Use walking aids, transfer belt, non slip shoes  Toileting regime (pts often fall trying to get to  Stay close to the patient washroom on time)  Tell patients to slow down  Transfer to the unaffected side  Encourage pt. to find a target to walk towards  Don’t rush (chair, doorway, family member)  Don’t attempt to transfer or walk with a patient  Have 2 assists when necessary if you don’t feel it is safe

A WORD ABOUT MOBILITY AND ATAXIA TAKE HOME MESSAGE

 Patients who present with co-ordination  Vision is a complex and important function problems can be difficult to manage when for everyday functioning. walking  Many older clients already have  They often present with good strength but can be decreased vision. very unsteady walking due to lack of control in their legs  Make visual screening a regular part of your assessment.  Often walkers do not provide the support they need  Know how to screen for common visual  May require 2 assists to transfer and walk issues.  SAFETY! Monitor clients with suspected visual inattention or field deficits closely to prevent falls.

8 2/22/2016

YOUR TURN: VISUAL FIELD CONFRONTATION TESTING BASIC VISUAL SCREENING FOR ACUTE STROKE PATIENTS

 Remember EYEGLASSES and room lighting  Sitting face to face, eyes at same level, test one eye at a time, then with both eyes open to look for  Visual fields – confrontation testing inattention.  Right, Left , both together  Upper, Middle, Lower quadrants Testing procedure:  Visual Acuity – object identification and reading. 1. Patient covers left eye. Test four quadrants of Right eye.  Occulomotor control – horizontal and vertical 2. Patient covers right eye. Test four quadrants of Left eye. visual tracking  Can use ‘number of fingers’ and ‘wiggling fingers’.  Visual inattention/neglect – clinical observations 3. Both eyes open: Test both Right and Left together to screen for visual inattention.

**?Where to position your fingers? If you can see it, then the patient can see it.**

REFERENCES

 Harvey, R., Macko, R., Stein, J., Winstein., C. & Zorowity. R. (2009). Stroke Recovery and Rehabilitation. Demo Medical Publishing, LLC.  Lotery, A.J., Wiggam, M.I., Jackson, J., Silvestri, G., Refson, K.Fullerton, K.J., et all. (2000). Correctable visual impairment in stroke rehabilitation patients. Age and Ageing, 29, 221-222.  Pedretti, L. (2001). Occupation Therapy : Pracitce Skills for Physical Dysfunction. Elsevier Science Health Science Division: Evaluation and Treatment of Visual Deficits Following Brain Injury (p. 532 – 572).  Scheiman, M. (2014). Understanding and Managing Visual Deficits after Stroke: A Guide for Therapists.  Warren, M. (1996). Pre-reading and Writing Exercises for Persons with Macular Scotomas. visABILITIES Rehab Services Inc.  Zoltan, B. (2007). Vision, Perception and Cognition. A Manual for the Evaluation and Treatment of the Adult with acquired Brain Injury, 4th Ed. SLACK incorporated.

9 2/22/2016

QUESTIONS?

Laura Swancar O.T. Reg. (Ont.) Occupational Therapist [email protected]

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