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DO YOU SEE WHAT I SEE?VISUAL DISTURBANCES FOLLOWING STROKE

ACUTE STROKE BEST PRACTICES WORKSHOP

“ADVANCING BEST PRACTICES IN ACUTE STROKE CARE”FEBRUARY 23, 2016

Laura Swancar O.T. Reg (Ont.)

Stroke Occupational Therapist

VISUAL DEFICITS FOLLOWING STROKE:OUTLINE

Why is vision important?

Common visual disturbances following stroke

Homonymous Hemianopsia

Assessment

Strategies/treatment

Unilateral Spatial Neglect

Safe Mobility in Patients with visualdisturbances and/or neglect following stroke

The “How to”: Basic visual field confrontationtesting in acute stroke

VISION IS IMPORTANT BECAUSE….

A. It is our most farreaching sense.

B. Related closely tobalance, safety andfall prevention.

C. Important formotor and posturalcontrol.

D. A key part of allour daily lifeactivities.

E. All of the above.

WHY IS VISION IMPORTANT?

Vision is our most far reaching sense

Provides speed and instant identification ofobjects and situations

Vision and mobility, balance, safety

Important part of motor and postural control(closed eyes item on Berg balance test)

Vision and the older patient

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VISUAL PERCEPTUAL HIERARCHYADAPTATION THROUGH VISION

Adaptation throughVisual Cognition

Visual Memory

Pattern RecognitionScanning

Attention = Alert and Attending

Visual Acuity, Visual field, OcculomotorControl

Warren, 1993

VISUAL DEFICITS AND DAILY LIFE

How does the disability affect a person’s DAILYACTIVITIES, WORK, LIFE ROLES?

Self care – washing, dressing, toileting, grooming

Home and community management – driving,reading, cooking, finances

Return to work

Mobility – safety

THREE COMPONENT MODEL OF VISION

MITCHELL SCHEIMAN, OD, FCOVD

Visual IntegrityVisual acuity

Refraction

Eye Health

Visual Fields

VisualInformationProcessing

Visual spatial skills

Visual Analysis skills

Visual motor integrationskills

Visual EfficiencyAccomodation

Binocular vision

Eye Movements

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VISUAL PROCESSING

HOMONYMOUS HEMIANOPSIA IS…..

A. A special type oforganic milk.

B. A condition affectinghalf the population.

C. Blindness in half thevision in both eyes.

D. A visual field deficit.

E. C and D.

F. A and C.

HOMONYMOUS HEMIANOPSIA

Also called Visual Field deficit

Blindness in ½ visual field of each eye

Quadrantanopsia – ¼ visual field of each eye

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BEHAVIOURAL CHANGES IN

HOMONYMOUS HEMIANOPSIA

Adopt a narrow search pattern confined tomidline and sound side

Person scans very slowly towards deficit side

Missing and /or “misidentifying” visual detail onthe “blind” side

Reduced visual monitoring of the hand

May feel unsafe due to loss of peripheral vision

Decreased engagement, withdraws socially

VISUAL FIELD DEFICIT:DAILY LIVING CHALLENGES

Driving

Shopping and community events

Yard Work

Meal preparation

Financial management

Functional communication

Housekeeping

Self care - grooming

HOMONYMOUS HEMIANOPSIA

BEST STRATEGY - EDUCATION

Compensation requires conscious cognitivestrategy – increase visual search strategies.

Must believe vision cannot be trusted on deficitside.

Awareness allows client to develop “intellectualover-ride”.

Develop awareness through practice.

Provide an anchor on the affected side

Ensure important items are in their intact visual

field

Encourage pacing to scan slowly

Use low vision devices like magnifying lenses

Ensure adequate lighting

Watch for glare

Increase visual contrasts

MORE STRATEGIES

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VISUAL INATTENTION OR

UNILATERAL SPATIAL NEGLECTVISUAL INATTENTION OR

UNILATERAL SPATIAL NEGLECT

Inability to attend or respond to stimulipresented opposite to the side of the brain lesion

Inattention/neglect of the one side of thebody or the person’s environment

Left neglect more common but Right sidedneglect possible

UNILATERAL SPATIAL NEGLECT

Associated with lower functional recovery anddecreased level of independence.

Significant implications for safety and falls.

Main therapy and education goal:

Increase awareness of neglected side.

UNILATERAL SPATIAL NEGLECT -COMMON BEHAVIOURS

Body (personal neglect) Leaves arm hanging at side of chair

Shaves only right side of face

Within reaching space (peripersonal space) Eats food only from right side of tray

Environment (extrapersonal space) Bumps into things on the left

Doesn’t attend to visitors sitting on left side ofbed/room

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STRATEGIES FOR VISUAL OR BODY NEGLECT

Ensure essential items, such as call bell,urinal, telephone are on good/intact side sothat they are accessible if needed

Approach the person on their best side (iefrom Right if left inattention)

Speak to person midline with eye contact –move to left side if possible

NEGLECT/INATTENTION

STRATEGIES CONTINUED

Position neglected arm in midline positionwithin visual field

Use a reference point or anchor

on left side

Help family to learn strategies byrespectful modeling and positivereinforcement

Encourage client to wash neglected side

Functional Category Observed Behaviour Strategies

Mobility

Walking

Wheelchair

transfers

Bumps into things/walls/people on the

left

FALLS, numerous close calls

Misses target in pivot transfers

-Supervision, frequent checks for needs

-Transfer belt, transfer to unaffected side

-Instructions to good side, eye contact

-Bed alarm

-grab bars for toilet/arm rests for chairs

ADL’s

washing

eating

toileting

grooming

dressing

Shave ½ face, eat ½ tray, wash ½ body

Clumsy/knocks over items

Misses important steps in tasks

Forgets to dress left side

-Position necessary items on good side

-Cues, reminder to wash left side

-Use anchor on left ie tea cup, red band, cell

phone

-Set up an organized and predictable

environment

-Dress affected side first, undress good side

first

Social Interactions Ignores visitors/family

Tires easily

Orients body and attention to right

side

-Help family to understand, teach strategies

-Encourage breaks/rest for client

Cognition/Thinking skills May have difficulty learning new skills

Poor insight and safety judgement

Difficulty reading

Inefficient visual scanning pattern

during activities ie ambulation

Rushes to complete tasks, no rechecks

-Important info to good side

-Respectful Repetition

-Supervision!

-Pay attention to level of cognitive FATIGUE

-Shorter sessions with frequent rests/breaks

UNILATERAL SPATIAL NEGLECT:STRATEGIES SUMMARY

VISUAL INATTENTION OR NEGLECT VERSUS

VISUAL FIELD DEFICIT: CONTINUUM

Visual neglect with noawareness

.….continuum……

Visual FieldDeficit with

full awareness

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Balance problems +visual deficits = high risk

for FALLS

SAFE MOBILITY IN PATIENTS

WITH HOMONYMOUS

HEMIANOSPIA

Fiona Maclean, Physiotherapist,

Regional Stroke Unit (RSU)

ALL STROKE PATIENTS SHOULD BE

CONSIDERED AT RISK OF FALLING

Presence of Unilateral Spatial Neglect has beenstrongly associated with increased risk of injury andwith poor functional outcomes

Patient’s have reduced ability to learn to compensatedue to the stroke, therefore repeated cuing andsupervision is required

PATIENTS WITH VISUAL FIELD DEFICIT

MAY:

Collide into their surroundings on one side(usually left) with walker or with their body

Fall if they run into objects or people, or trip overitems.

Most patients also have weakness and reducedbalance which makes it harder to regain balanceif they do bump into objects.

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HOW YOU CAN HELP WHEN WALKING WITH

PATIENT

Ensure both hands are on walker, may need toassist hand to stay on walker

Stand on the patients’ affected side

Provide cueing – verbal, tactile to assist patientto attend to affected side

Use walking aids, transfer belt, non slip shoes

Stay close to the patient

Tell patients to slow down

Encourage pt. to find a target to walk towards(chair, doorway, family member)

Have 2 assists when necessary

FALL PREVENTION

Stress importance of safety and calling for help toget out of bed (have call bell within visual field)

Bed alarms on, bed in lowest position

Attach call bell to pts. gown if you think they arelikely to get up on their own

Toileting regime (pts often fall trying to get towashroom on time)

Transfer to the unaffected side

Don’t rush

Don’t attempt to transfer or walk with a patientif you don’t feel it is safe

A WORD ABOUT MOBILITY AND ATAXIA

Patients who present with co-ordinationproblems can be difficult to manage whenwalking

They often present with good strength but can bevery unsteady walking due to lack of control intheir legs

Often walkers do not provide the support theyneed

May require 2 assists to transfer and walk

TAKE HOME MESSAGE

Vision is a complex and important function

for everyday functioning.

Many older clients already have

decreased vision.

Make visual screening a regular part

of your assessment.

Know how to screen for common visual

issues.

SAFETY! Monitor clients with suspected visualinattention or field deficits closely to preventfalls.

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BASIC VISUAL SCREENING

Remember EYEGLASSES and room lighting

Visual fields – confrontation testing

Right, Left , both together

Upper, Middle, Lower quadrants

Visual Acuity – object identification and reading.

Occulomotor control – horizontal and verticalvisual tracking

Visual inattention/neglect – clinical observations

YOUR TURN:VISUAL FIELD CONFRONTATION TESTING

FOR ACUTE STROKE PATIENTS

Sitting face to face, eyes at same level, test one eye ata time, then with both eyes open to look forinattention.

Testing procedure:1. Patient covers left eye. Test four quadrants of Right eye.

2. Patient covers right eye. Test four quadrants of Left eye. Can use ‘number of fingers’ and ‘wiggling fingers’.

3. Both eyes open: Test both Right and Left together toscreen for visual inattention.

**?Where to position your fingers? If you can see it, then thepatient 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 rehabilitationpatients. Age and Ageing, 29, 221-222.

Pedretti, L. (2001). Occupation Therapy : Pracitce Skills for PhysicalDysfunction. Elsevier Science Health Science Division: Evaluation andTreatment of Visual Deficits Following Brain Injury (p. 532 – 572).

Scheiman, M. (2014). Understanding and Managing Visual Deficits afterStroke: A Guide for Therapists.

Warren, M. (1996). Pre-reading and Writing Exercises for Persons withMacular Scotomas. visABILITIES Rehab Services Inc.

Zoltan, B. (2007). Vision, Perception and Cognition. A Manual for theEvaluation and Treatment of the Adult with acquired Brain Injury, 4th

Ed. SLACK incorporated.

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QUESTIONS?

Laura Swancar O.T. Reg. (Ont.)

Occupational Therapist

swancarl@tbh.net