Occupational Therapy Department P/OTD 541 Critical Analysis of Occupational Therapy Practice | Creighton University OTD 601 Capstone CRITICALLY APPRAISED TOPIC (CAT) WORKSHEET Focused Question: What is the effectiveness of visual scanning techniques on performance of basic activities of daily living for adults who have hemianopsia/hemianopia following a stroke? Prepared By: Jennifer Hefner [email protected] Department of Occupational Therapy School of Pharmacy & Health Professions Creighton University 2500 California Plaza Omaha, NE 68178 Supervised by Vanessa Jewell, MS, OTR/L, PhD Candidate 2014, Texas Woman’s University, Assistant Professor of Occupational Therapy ([email protected]) René Padilla, PhD, OTR/L, FAOTA, Associate Professor of OT and Associate Dean for Academic Affairs ([email protected]) Date Review Completed: November 14, 2014 Clinical Scenario: According to the Centers for Disease Control and Prevention (CDC), stroke is the fourth leading cause of death and a major cause of disability within the United States (CDC, 2014). Approximately 795, 000 people in the United States experience a stroke each year (American Stroke Association, 2014). Many of those that survive experiencing a stroke are left with physical limitations, including vision problems. Approximately 20% to 57% of individuals who have had a stroke will experience visual field defects (Pollock et al., 2011). There are various types of visual field defects, one being hemianopsia, also known as hemianopia, which pertains to the loss of vision in one-half of the visual field in the eye (Warren, 2011). Hemianopsia occurs most commonly in individuals who have experienced a vascular issue within the posterior cerebral artery (Warren, 2011). As a result of hemianopsia, individuals may experience an alteration in activities of their daily lives. More specifically, individuals who have hemianopsia may have difficulties seeing small, low-contrast items as well as items in their environment that are inhibited by their lack of vision within that field (Warren, 2009). Occupational therapists strive to assist clients in achieving their goals related to activities of daily living (ADLs) (AOTA, 2014). Because there is a high occurrence of visual field defects post-stroke, treatment methods should be explored to help increase performance in activities of daily living (Pollock et al., 2011). Visual scanning techniques are a common form of intervention that occupational therapy practitioners use to assist individuals with hemianopsia in their daily lives. Visual scanning techniques pertain to any method of visual search training of the environment or a task that can eventually be relayed to daily activities (Warren, 2011). If individuals are able to discover their best visual search pattern, the hope is that this technique 1 Adapted from AOTA Evidence-Based Literature Review Project/CAT Worksheet.5-05 may be utilized to better perform daily tasks. Therefore, occupational therapists need to explore the effectiveness of this treatment intervention for those with hemianopsia following a stroke in order to find the best treatment options. Summary of Key Findings: Summary of Levels I, II, and III All areas of ADLs showed significant improvement following a visual scanning training program (Nelles et al., 2001; Level II; Pambakian, Mannan, Hodgson, & Kennard, 2004, Level III; Sabel, Kenkel, & Kasten, 2004, Level III). More specifically, improvements in visual confidence and mobility, better reading, and fewer instances of bumping into objects or people was noted (Sabel et al., 2004, Level III). Following the completion of a home-based visual training program, significant improvements in response time were noted (Lane, Smith, Ellison, & Schenk, 2010, Level II). Following visual exploration training and attention training, participants demonstrated significant improvements in most visual tasks (Lane et al., 2010, Level II). Reading was the only item to show a significant improvement after exploration training when compared with other daily tasks (Lane et al., 2010, Level II). Following a visual scanning program, there was a trend that the participants performed ADL tasks faster. A significant correlation was noted between the participants’ ages and magnitudes of improvement in time required to complete ADL tasks (Pambakian et al., 2004, Level III). Summary of Level IV NVT vision rehabilitation program (structured and standardized) had a significant impact on attainment of skills and quality of life in patients with homonymous hemianopia post acquired brain injury. Benefits were maintained three months following rehabilitation (Hayes, Chen, Clarke, & Thompson, 2012, Level IV). Following a NVT vision rehabilitation program, improvements in functional mobility and response time were made and maintained three months following the training (Hayes et al., 2012, Level IV). Contributions of Qualitative Studies: None included in the review Bottom Line for Occupational Therapy Practice: The clinical and community-based practice of OT: All of the studies explored demonstrated that there was an increase in ADL performance following visual scanning techniques (Hayes et al., 2012, Level IV; Lane et al., 2010, Level II; Nelles et al., 2001, Level II; Pambakian et al., 2004, Level III; Sabel et al., 2004, Level III). An NVT intervention and light training board at an inpatient or outpatient setting proved to demonstrate positive effects on ADLs (Hayes et al., 2012, Level IV; Nelles et al., 2001, Level II). On the other hand, computer-based visual scanning programs proved to be beneficial and can be implemented in outpatient or home health settings (Lane et al., 2010, Level II; Pambakian et al., 2004, Level III; Sabel et al., 2004, Level 2 Adapted from AOTA Evidence-Based Literature Review Project/CAT Worksheet.5-05 III). The results from this exploration of a focus question demonstrated that visual scanning techniques in any setting may help improve ADL performance. The studies explored also used different means (computers, light boards, and standardized protocols) as visual scanning techniques, allowing therapists to select from several different methods that best suit their patient. Further research is needed to increase the level of evidence though. All of the studies explored used smaller, non-random sample sizes (Hayes et al., 2012, Level IV; Lane et al., 2010, Level II; Nelles et al., 2001, Level II; Pambakian et al., 2004, Level III; Sabel et al., 2004, Level III). Program development: Further research should be performed to increase the level of evidence for all articles explored (Hayes et al., 2012, Level IV; Lane et al., 2010, Level II; Nelles et al., 2001, Level II; Pambakian et al., 2004, Level III; Sabel et al., 2004, Level III). Due to this, currently it would be recommended to include visual scanning techniques for adults who have hemianopsia/hemianopia as a portion of rehabilitation services but not the entire program (Hayes et al., 2012, Level IV; Lane et al., 2010, Level II; Nelles et al., 2001, Level II; Pambakian et al., 2004, Level III; Sabel et al., 2004, Level III). The programs that include light boards or standardized protocols may be best fit to be part of a plan of care for an inpatient or outpatient setting for adults who have hemianopsia/hemianopia (Hayes et al., 2012, Level IV; Nelles et al., 2001, Level II). Computer-based visual scanning techniques for outpatient or home health settings may be utilized as a component of a vision program for those to have hemianopsia/hemianopia (Lane et al., 2010, Level II; Pambakian et al., 2004, Level III; Sabel et al., 2004, Level III). Further research is needed to explore program development methods and settings. Societal needs: An increase in performance of ADLs was noted following visual scanning techniques throughout the course of this research process (Hayes et al., 2012, Level IV; Lane et al., 2010, Level II; Nelles et al., 2001, Level II; Pambakian et al., 2004, Level III; Sabel et al., 2004, Level III). Furthermore, having an increase in ADL performance for adults with hemianopsia/hemianopia may meet the needs of fiscal conservancy by reducing the need for assistance or further services in the future (Hayes et al., 2012, Level IV; Lane et al., 2010, Level II; Nelles et al., 2001, Level II; Pambakian et al., 2004, Level III; Sabel et al., 2004, Level III). Visual scanning programs that are implemented within homes of adults with hemianopsia/hemianopia also provide fiscal conservancy as there is minimal cost, and it is more convenient for the individuals (Lane et al., 2010, Level II; Pambakian et al., 2004, Level III; Sabel et al., 2004, Level III). Also, the home computer programs are portable and easy-toaccess, maximizing repetitions for the population (Lane et al., 2010, Level II; Pambakian et al., 2004, Level III; Sabel et al., 2004, Level III). Two articles utilized equipment (training boards) that may be expensive and not easily available to purchase for participants or rehabilitation facilities (Hayes et al., 2012, Level IV; Nelles et al., 2001, Level II). Again, further research should be performed by facilities/therapists before investing in specific visual scanning programs. Healthcare delivery and health policy: Currently, the research of this focus question does not support that visual scanning techniques alone should be implemented as a policy for healthcare delivery, as stronger evidence needs to be performed on this preliminary research (Hayes et al., 2012, Level IV; Lane et al., 2010, Level II; Nelles et al., 2001, Level II; Pambakian et al., 2004, Level III; Sabel et al., 2004, Level III). More rigorous research should be performed using a larger, non-random sample size to increase the level of evidence (Hayes et al., 2012, Level IV; Lane et al., 2010, Level II; Nelles et al., 2001, Level II; Pambakian et al., 2004, Level III; Sabel 3 Adapted from AOTA Evidence-Based Literature Review Project/CAT Worksheet.5-05 et al., 2004, Level III). Also, future research should be implemented on the specific visual scanning protocols, comparing them to controls and varying frequencies and durations (Hayes et al., 2012, Level IV; Pambakian et al., 2004, Level III; Sabel et al., 2004, Level III). More research does need to be performed on reliability and validity of any equipment that is utilized before a study can be considered to impact policies within healthcare (Hayes et al., 2012, Level IV; Lane et al., 2010, Level II; Nelles et al., 2001, Level II; Pambakian et al., 2004, Level III; Sabel et al., 2004, Level III). Education and training of OT student: Visual scanning techniques for clients/patients with hemianopsia/hemianopia is currently part of entry-level occupational therapy practice. Students are taught basic vision rehabilitation techniques to guide/assist patients to help increase ADL participation and functional performance. The studies explored in this focus question demonstrated an increase in ADL performance following visual scanning techniques, thus occupational therapy curriculum should continue to implement vision rehabilitation as a part of its didactic coursework (Hayes et al., 2012, Level IV; Lane et al., 2010, Level II; Nelles et al., 2001, Level II; Pambakian et al., 2004, Level III; Sabel et al., 2004, Level III). However, further continuing education or guidance as to using certain visual scanning protocols and equipment may be needed to initiate the programs properly (Hayes et al., 2012, Level IV; Lane et al., 2010, Level II; Nelles et al., 2001, Level II; Pambakian et al., 2004, Level III; Sabel et al., 2004, Level III). Occupational therapy also has a Low Vision Specialty Certification that practitioners can obtain in order to acquire more knowledge about vision rehabilitation. Refinement, revision, and advancement of factual knowledge or theory: While the results of these studies demonstrated positive effects, further research regarding this focus question is warranted, as all of the articles appraised were not of the highest level of evidence. Research should be performed with a larger, randomized group of adults with hemianopsia/hemianopia because all of the studies explored were small, convenience samples (Hayes et al., 2012, Level IV; Lane et al., 2010, Level II; Nelles et al., 2001, Level II; Pambakian et al., 2004, Level III; Sabel et al., 2004, Level III). Also, over half of the articles appraised did not contain control groups, and for those that did they were not discussed in detail, so further research should explore comparisons with controls (Hayes et al., 2012, Level IV; Pambakian et al., 2004, Level III; Sabel et al., 2004, Level III). In future research, participants should not be exposed to the training programs beforehand (Nelles et al., 2001, Level II; Pambakian et al., 2004). Three of the articles used a home-based computer program as the intervention, which may expose the participants to other extraneous variables that could affect the results of the study (Lane et al., 2010, Level II; Pambakian et al., 2004, Level III; Sabel et al., 2004, Level III). Therefore future research should monitor home-based programs closely to eliminate extraneous variables. One study had a high correlation of age and improvement in ADLs, so future research should investigate this correlation (Pambakian et al., 2004). Visual scanning programs can include numerous types of protocols with varying frequencies and durations, as well as a variety of equipment. Due to this, future research should explore all of these different types to find what is most effective for adults with hemianopsia/hemianopia, as well as the long-term effects (Hayes et al., 2012, Level IV; Lane et al., 2010, Level II; Nelles et al., 2001, Level II; Pambakian et al., 2004, Level III; Sabel et al., 2004, Level III). Review Process A literature search for potential focus questions was performed by searching online databases and reviewing abstracts. Adapted from AOTA Evidence-Based Literature Review Project/CAT Worksheet.5-05 4 Focus question was developed and submitted for review from faculty mentor. Focus question approved. A comprehensive literature search began and Medical Subject Headings (MeSH) were formulated. A search of all relevant databases was performed individually to ensure all appropriate articles were obtained. Selected articles met inclusion criteria for focused question. A total of fourteen articles was submitted for faculty review from the comprehensive literature search. Citations and abstracts were provided. Faculty mentor performed a follow-up search and approved comprehensive literature search with no additions or exclusions to the list. Results from comprehensive literature search were analyzed further using inclusion/exclusion criteria for articles to be included in evidence table. Email and personal consultation with faculty mentor was performed to assist in determining appropriate articles for evidence table. Level I articles excluded due to repeat of articles and not being a good representation of the focus question. After excluding nine articles, a total of five articles was submitted for faculty mentor review within the evidence table. Faculty mentor appraised and approved evidence table. Using the evidence table, a CAT was formulated and submitted for faculty mentor review. Procedures for the selection and appraisal of articles Inclusion Criteria: Published in a peer-review journal Written in English Articles Level I-IV All years searched Articles that included the PIO of the focus question Outcomes measure included a measurement of activities of daily living performance per the Occupational Therapy Practice Framework (OTPFW) (AOTA, 2014) Intervention must be a visual scanning technique per the description above Participants must be adults that have hemianopsia/hemianopia following a stroke Exclusion Criteria: Articles that were Level V Theses, dissertations, or opinion papers Qualitative articles Articles that were not peer-reviewed Articles that did not meet PIO inclusion criteria Individuals with visual inattention that cannot be differentiated from hemianopsia/hemianopia Articles that did not measure activities of daily living per the OTPFW (AOTA, 2014) Level I articles that had overlap between other Level I articles or were not a good representation of the focus question were excluded. Individual articles pertaining to the focus question were individually reviewed from the Level I articles. Search Strategy Categories 5 Key Search Terms Adapted from AOTA Evidence-Based Literature Review Project/CAT Worksheet.5-05 Patient/Client Population Intervention Outcomes Comparison Hemianopsia, hemianopia, visual field deficit, visual field cut, homonymous hemianopsia, bitemporal hemianopsia, binasal hemianopsia Visual scanning techniques, visual scanning patterns, visual search patterns, visual search strategies, visual scanning strategies, visual field training, compensatory visual scanning, visual exploration training, rehabilitation Activities of daily living, bathing, showering, toileting, dressing, swallowing/eating, feeding, functional mobility, personal device care, personal hygiene/grooming, sexual activity None explored Databases and Sites Searched CINAHL, Medline Complete, Cochrane Library, AgeLine, PsycARTICLES, PsycINFO, OTSeeker, OTSearch, JAMAevidence, AJOT, GoogleScholar, PubMed Quality Control/Peer Review Process: Focus question was reviewed by faculty mentor. Faculty mentor approved focus question. Comprehensive literature search submitted and reviewed by faculty mentor. Faculty mentor performed follow-up comprehensive literature search to ensure search was complete and exhaustive. No changes were made. Email communication and personal discussion with faculty mentor regarding inclusion/exclusion of articles for the evidence table. Evidence table was reviewed by faculty mentor and approved. Evidence table utilized to complete CAT. CAT submitted for faculty mentor review. Results of Search Summary of Study Designs of Articles Selected for Appraisal Level of Evidence I II III IV V Study Design/Methodology of Selected Articles Systematic reviews, meta-analysis, randomized controlled trials Two groups, nonrandomized studies (e.g., cohort, case-control) One group, nonrandomized (e.g., before and after, pretest, and posttest) Descriptive studies that include analysis of outcomes (single subject design, case series) Case reports and expert opinion, which include narrative literature reviews and consensus statements Qualitative Studies Number of Articles Selected 0 2 2 1 0 TOTAL 6 0 5 Adapted from AOTA Evidence-Based Literature Review Project/CAT Worksheet.5-05 Limitations of the Studies Appraised Levels I, II, and III A small, non-random convenience sample was used (Lane et al., 2010, Level II; Nelles et al., 2001, Level II; Pambakian et al., 2004, Level III; Sabel et al., 2004, Level III). A control group was not used (Nelles et al., 2001, Level II; Pambakian et al., 2004, Level III; Sabel et al., 2004, Level III). Information was not given regarding location of outcome measures or supervision (Lane et al., 2010, Level II; Nelles et al., 2001, Level II; Pambakian et al., 2004, Level III). Compliance could be questionable with a home-based visual scanning program. A home based program also increases the amount of possible extraneous variables affecting the results (Lane et al., 2010, Level II; Pambakian et al., 2004, Level III). Participants were trained prior to the study, increasing risk of learned use of the training program and testing measures (Nelles et al., 2001, Level II; Pambakian et al., 2004, Level III). There were individual differences in severity of visual deficits between the two sample groups (Lane et al., 2010, Level II). Frequency and duration of the two different interventions compared were not the same, making it difficult to compare interventions. Task difficulty also varied for each participant, varying comparability as well (Lane et al., 2010, Level II). Study objective was not stated and information from each research component was very brief (Nelles et al., 2001, Level II). Minimal information given as to what the comparison group performed (Nelles et al., 2001, Level II). Participants were divided into sub-groups, but little information was provided (Sabel et al., 2004, Level III). The subjective visual disorder questionnaires were unreliable (Pambakian et al., 2004, Level III). Subjective ADL information was used in testimonies (qualitative) and published in another study. The authors did not state the results; however, compared it to the ADL questionnaire in this study. It would have been beneficial if the authors would have briefly stated the results from the interviews (Sabel et al., 2004, Level III). ADL tasks consisted of very fine motor tasks as well. Decreased fine motor skills may contribute to a skewed performance with tasks (Pambakian et al., 2004, Level III). Levels IV and V The sample size was small and non-random. A control or comparison group was not used (Hayes et al., 2012, Level IV). An intervention location was not made known (Hayes et al., 2012, Level IV). Specific significance levels were not utilized when discussing the results (Hayes et al., 2012, Level IV). Articles Selected for Appraisal 7 Adapted from AOTA Evidence-Based Literature Review Project/CAT Worksheet.5-05 Hayes, A., Chen, C. S., Clarke, G., & Thompson, A. (2012). Functional improvements following the use of the NVT Vision Rehabilitation program for patients with hemianopia following stroke. Neurorehabilitation, 31(1), 19-30. Lane, A., Smith, D., Ellison, A., & Schenk, T. (2010). Visual exploration training is no better than attention training for treating hemianopia. Brain: A Journal of Neurology, 133(6), 1717-1728. Nelles, G., Esser, J., Eckstein, A., Tiede, A., Gerhard, H., & Diener, H. (2001). Compensatory visual field training for patients with hemianopia after stroke. Neuroscience Letters, 306(3), 189-192. Pambakian, A., Mannan, T. L., Hodgson, T. L., & Kennard, C. (2004). Saccadic visual search training: A treatment for patients with homonymous hemianopia. Journal of Neurology, Neurosurgery, and Psychiatry 75(10), 1443-1448. Sabel, B. A., Kenkel, S., & Kasten, E. (2004). Vision restoration therapy (VRT) efficacy as assessed by comparative perimetric analysis and subjective questionnaires. Restorative Neurology & Neuroscience, 22(6), 399-420. Other References American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 69(1), S1-S48. American Stroke Association. (2014, May 27). Impact of stroke. Retrieved from http://www.strokeassociation.org/STROKEORG/AboutStroke/Impact-of-Stroke-Strokestatistics_UCM_310728_Article.jsp Centers for Disease Control and Prevention. (2014, June 18). Stroke. Retrieved from http://www.cdc.gov/stroke/index.htm Pollock, A., Hazelton, C., Henderson, C., Angilley, J., Dhillon, B., Langhorne, P., & ... Shahani, U. (2011). Interventions for visual field defects in patients with stroke. Cochrane Database of Systematic Reviews, 10, 37-38. doi: 10.1002/14651858.CD008388.pub2. Warren, M. (2009). Pilot study on activities of daily living limitations in adults with hemianopsia. American Journal of Occupational Therapy, 63, 626–633. Warren, M. (2011). Intervention for adults with vision impairment from acquired brain injury. In M. Warren & E. A. Barstow (Eds.), Occupational therapy interventions for adults with low vision (403-448). Bethesda, MD: AOTA Press. 8 Adapted from AOTA Evidence-Based Literature Review Project/CAT Worksheet.5-05
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