Monica S. Perlmutter

Screening Patients with Stroke for Rehabilitation Needs: Validation of the Post-Stroke Rehabilitation Guidelines

Background. The authors assessed patients with acute stroke to determine whether the systematic use of brief screening measures would more efficiently detect cognitive and sensory impairment than standard clinical practice. Methods. Fifty-three patients admitted to an acute stroke unit were assessed within 10 days of stroke onset. Performance on the screening measures was compared to information obtained from review of the patient’s chart at discharge. Cognition, language, visual acuity, visual-spatial neglect, hearing, and depression were evaluated. Results. Formal screening detected significantly more impairments than were noted in patient charts in every domain. Only 3 patients had no impairments identified on screening; all remaining patients had at least 1 impairment detected by screening that was not documented in the chart. Thirty-five percent had 3 or more undetected impairments. Memory impairment was most likely to be noted in the chart; for all other domains tested, undocumented impairment ranged from 61% (neglect) to 97% (anomia). Conclusion. Many acute stroke patients had cognitive and perceptual deficits that were not documented in their charts. These data support the Post-Stroke Rehabilitation Guidelines for systematic assessment even when deficits are not immediately apparent. Systematic screening may improve discharge planning, rehabilitation treatment, and long-term outcome of persons with stroke.

Responsiveness of the EQ-5D to the effects of low vision rehabilitation.

Purpose This study is an evaluation of the responsiveness of preference-based outcome measures to the effects of low vision rehabilitation (LVR). It assesses LVR-related changes in EQ-5D utilities in patients who exhibit changes in Activity Inventory (AI) measures of visual ability. Methods Telephone interviews were conducted on 77 low-vision patients out of a total of 764 patients in the parent study of “usual care” in LVR. Activity Inventory results were filtered for each patient to include only goals and tasks that would be targeted by LVR. Results The EQ-5D utilities have weak correlations with all AI measures but correlate best with AI goal scores at baseline (r = 0.48). Baseline goal scores are approximately normally distributed for the AI, but EQ-5D utilities at baseline are skewed toward the ceiling (median, 0.77). Effect size for EQ-5D utility change scores from pre- to post-LVR was not significantly different from zero. The AI visual function ability change scores corresponded to a moderate effect size for all functional domains and a large effect size for visual ability measures estimated from AI goal ratings. Conclusions This study found that the EQ-5D is unresponsive as an outcome measure for LVR and has poor sensitivity for discriminating low vision patients with different levels of ability.

Home Lighting Assessment for Clients With Low Vision

OBJECTIVE The goal was to develop an objective, comprehensive, near-task home lighting assessment for older adults with low vision. METHOD A home lighting assessment was developed and tested with older adults with low vision. Interrater and test-retest reliability studies were conducted. Clinical utility was assessed by occupational therapists with expertise in low vision rehabilitation. RESULTS Interrater reliability was high (intraclass correlation coefficient [ICC] = .83-1.0). Test-retest reliability was moderate (ICC = .67). Responses to a Clinical Utility Feedback Form developed for this study indicated that the Home Environment Lighting Assessment (HELA) has strong clinical utility. CONCLUSION The HELA provides a structured tool to describe the quantitative and qualitative aspects of home lighting environments where near tasks are performed and can be used to plan lighting interventions. The HELA has the potential to affect assessment and intervention practices of rehabilitation professionals in the area of low vision and improve near-task performance of people with low vision.

Differences in Vision Between Clinic and Home and the Effect of Lighting in Older Adults With and Without Glaucoma

IMPORTANCE Patients often report greater visual difficulties at home than expected from vision testing in the clinic. Such discordance may be owing to worse vision in the home than measured in clinic. OBJECTIVE To compare vision measured between the clinic and home and evaluate factors, including lighting, associated with these differences. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study conducted from 2005-2009 involved 126 patients with glaucoma and 49 without glaucoma recruited from the Glaucoma and Comprehensive Eye Clinics at Washington University, St Louis, Missouri. Patients underwent clinic and home visits, were aged 55 to 90 years, were consecutively recruited, and met inclusion criteria for this study. A total of 166 eligible patients refused participation. EXPOSURE Participants underwent clinic and home visits randomized to order of completion. At each visit, masked and certified examiners measured binocular distance visual acuity (DVA) with a nonbacklit chart, near visual acuity (NVA), contrast sensitivity (CS), CS with glare, and lighting. MAIN OUTCOMES AND MEASURES Differences in vision between the clinic and home. RESULTS The mean scores for all vision tests were significantly better in the clinic than home for participants with and without glaucoma (P < .05, matched-pair t tests). For DVA, 29% of participants with glaucoma read 2 or more lines better in the clinic than home and 39% with advanced glaucoma read 3 or more lines better. For the entire sample, 21% of participants read 2 or more lines better in the clinic than home for NVA and 49% read 2 or more triplets better in the clinic for CS with glare. Lighting was the most significant factor associated with differences in vision between the clinic and home for DVA, NVA, and CS with glare testing (P < .05, multiple regression model). Median home lighting was 4.3 times and 2.8 times lower than clinic lighting in areas tested for DVA and NVA, respectively. Home lighting was below that recommended in 85% or greater of participants. CONCLUSIONS AND RELEVANCE Vision measured in the clinic is generally better than vision measured at home, with differences mainly owing to poor home lighting. Knowledge that vision discrepancies between patient report and clinical testing may be owing to home lighting may initiate clinician-patient discussions to optimize home lighting and improve the vision of older adults in their homes.

Factors Affecting Readiness for Low Vision Interventions in Older Adults.

OBJECTIVE We sought to identify factors that facilitate and inhibit readiness for low vision interventions in people with vision loss, conceptualized as readiness for change in the way they perform daily activities. METHOD We conducted 10 semistructured interviews with older adults with low vision and analyzed the results using grounded theory concepts. RESULTS Themes involving factors that facilitated change included desire to maintain or regain independence, positive attitude, and presence of formal social support. Themes related to barriers to change included limited knowledge of options and activity not a priority. Themes that acted as both barriers and facilitators were informal social support and community resources. CONCLUSION This study provides insight into readiness to make changes in behavior and environment in older adults with vision loss. Study findings can help occupational therapy practitioners practice client-centered care more effectively and promote safe and satisfying daily living activity performance in this population.

Using integrated learning experiences to promote clinical competence: an instructional case study

ABSTRACT This case study describes a novel end-of-semester instructional method that ties together content between courses at three points during an entry-level occupational therapy curriculum. In these integrated curriculum event, known as the ‘ICE’, small groups of students work together to perform portions of the OT process in the context of a case study. Early evidence suggests that the ICE breaks down the silos between courses and fosters higher-order thinking and increasingly advanced clinical reasoning.