brk 4 - AACPDM

Occupational Therapy and Physical Therapy
Therapeutic Recreation
Cortical
Visual
Impairment
Karen Harpster, PhD, OTR/L
Karen.Harpster@cchmc.org
Tricia Gribben, OTR/L
patricia.Gribben@cchmc.org
AACPDM 2016
Disclosure Information
AACPDM 70th Annual Meeting | September 20-24, 2016
Speaker Names:
Karen Harpster and Tricia Gribben
We have no financial relationships to disclose.
We will not discuss off label use and/or
investigational use in my presentation
Occupational Therapy and Physical Therapy
Objectives
At the end of this presentation, the learner will be able
to:
• Describe the current body of evidence on therapeutic
interventions for children with cortical visual
impairment (CVI)
• Describe the behavioral characteristics common in
children with CVI and use of the CVI Range
• Explain environmental adaptations, task adaptations,
and treatment planning for children with CVI
• Discuss treatment planning for children with CVI and
caregiver engagement
Occupational Therapy and Physical Therapy
Why is it important?
• Currently, CVI is one of the leading causes of visual
impairment, affecting a large number of patients
seen by occupational therapists
• Visual skills have a significant impact on
development of gross and fine motor skills
• Therapists can make simple modifications to task and
environment to enhance functional visual skills
Occupational Therapy and Physical Therapy
There are 2 types of visual disorders:
1. Ocular disorders where the pathology of the
eye(s) is directly impacted.
1. Neurological disorders where there is
impaired or reduced vision due to an
impairment or injury to the brain.
CVI is a neurological visual disorder, and it is the
fastest growing visual impairment diagnosis
today.
Occupational Therapy and Physical Therapy
What is CVI?
• Cortical Visual Impairment is when the eye
works fine but part of the brain that interprets
signals from the eye does not.
• The brain does not consistently understand or
interpret what the eyes see.
Occupational Therapy and Physical Therapy
Medical Conditions Typically
Associated with CVI
• Periventricular Leukomalacia (PVL)
• Asphyxia/Hypoxic Ischemic Encephalopathy
• CVA (stroke)
Occupational Therapy and Physical Therapy
Medical Conditions Typically
Associated with CVI, -cont.• Intraventricular Hemorrhage
• Structural Abnormalities
• Trauma (i.e. head injury)
• Metabolic
Occupational Therapy and Physical Therapy
CVI Range
• Developed by Christine Roman-Lantzy
• 10 characteristics that define CVI
Occupational Therapy and Physical Therapy
Characteristics associated with CVI:
1. Color preference
•
Preference for bright colors/high contrast
2. Need for movement
– Shiny/reflecting or moving
3. Visual latency
Occupational Therapy and Physical Therapy
Characteristics associated with CVI:
4. Visual field preferences
– Lower and midline are hardest
5. Difficulties with visual complexity
– Object – progress from single color to multiple
colors
– Environment - Visual and auditory
Occupational Therapy and Physical Therapy
Characteristics associated
with CVI, -cont.6. Light gazing and non purposeful gaze
7. Difficulty with distance viewing
8. Atypical visual reflexes
– Touch bridge of nose
– Quick object towards face
Occupational Therapy and Physical Therapy
Characteristics associated
with CVI, -cont.9. Difficulty with visual novelty
– Can see familiar object better than novel
10. Absence of visually guided reach
– Look then reach
Occupational Therapy and Physical Therapy
CVI Phases for intervention
1. Phase I: (CVI Range scores 1-3) The major goal of
this phase is to build consistent visual behaviors
2. Phase 2: (CVI Range scores 4-7) The major goal is
to integrate vision into all functional routines
3. Phase 3: (CVI Range scores 8-10) The major goal is
to demonstrate visual curiosity and to consistently
and spontaneously use vision in all tasks
Occupational Therapy and Physical Therapy
Common Phase 1 Behaviors:
1. Have strong color preference
2. Strong interest in objects with movement properties
3. Ignore objects with either multiple colors/patterned
surface or presented against patterned backgrounds
4. Delay in visual response to objects even when familiar
objects are presented
5. Have certain objects they recognized before all others,
especially before new objects
Occupational Therapy and Physical Therapy
Phase 1
Environmental Modifications:
• Large focus on environmental modifications
• Need to focus on one sense at a time (vision)
• The lights should be dimmed if possible
• Eliminating clutter that will distract the child
• Use black background
• Quiet treatment area
• Visual target should be shiny
and a single color
Occupational Therapy and Physical Therapy
Phase 1
Visual Attention:
• Children in this phase spend little time looking or
visually attending to an object or environment
• Objects need to be held close to the patients face
(within 12 inches)
Occupational Therapy and Physical Therapy
Phase 1 Intervention
• Focus on increasing the number and duration of glances at an
object
• Objects used should be:
• Preferred, single color
• Moving
• Shiny/reflective properties
• The same 3-5 objects should be used consistently in the
beginning to increase glances
Occupational Therapy and Physical Therapy
Phase 1 Intervention
• Once the child increases the number of glances toward
an object, you can work on increasing the duration of
looking at the object
• Some common objects that are usually preferred by
children in phase 1 are slinky, reflective pinwheel, shiny
pom poms, different color flashlights, light up toys, etc.
Occupational Therapy and Physical Therapy
Common toys for phase 1
http://www.starlight.com/confettimylar.html
http://www.lulusoso.com/products/Flashing-Multi-ColorsPuffer-Ball.html
http://www.worldtwirling.com/html/ch
eerleading_supplies__pom_pom.htm
l
http://sell.lulusoso.com/sellingleads/733415/33-quot-7-mm-AssortedMardi-Gras-Beads-necklace.html
http://www.goodnewsweekly.ca/2010/1
1/most-popular-toys-from-1940s.html
Occupational Therapy and Physical Therapy
http://pinside.com/pinball/forum/topic/avengers-mods
Common Phase 2 Behaviors:
• Exhibit more consistent eye to object contact
with objects of preferred color
• Begin to look at objects with one or two
additional colors and simple patterns
Occupational Therapy and Physical Therapy
Phase 2 Intervention
Goal: Integrate vision with function
• All activities should encourage the child to use
their vision to make something happen
• Swatting at objects, switch toys, cause and effect,
vibrating toys, etc.
Occupational Therapy and Physical Therapy
Phase 2 Intervention
• Activities should combine vision with touch, swat, reach,
grasp, or eye-gaze in order to accomplish the task
• ADL tasks (reaching for comb wrapped in mylar)
• Fine motor (reaching for sparkly pom poms)
• Improvements are typically seen in abilities to maintain visual
contact with people and objects in controlled settings
Occupational Therapy and Physical Therapy
Phase 2 Environmental Modifications
for Therapy
• Toys should have no more than 2-3 colors
• Consider the complexity of the environment; There may be
difficulty visually attending in a busy therapy gym with a lot of
clutter or loud noise
• Visual target should be placed no farther 18 inches from face
(depending on activity)
• As the motor demand of the task increases, decrease the
visual demand of the task
• Fewer toys out at one time better. For example, with block
stacking, hand them 1-2 at a time
Occupational Therapy and Physical Therapy
Environmental adaptations using technology :
• Take pictures of three dimensional items on a
tablet
• Show the picture of the item on the tablet
• This will allow for moving from viewing three
dimensional items into viewing two
dimensional items
Occupational Therapy and Physical Therapy
Environmental adaptations using
technology ( cont.)
• Take pictures of two dimensional materials such as
books and allow child to look at each page, swiping
to turn the page if able
• The back lighting of the tablet assists with viewing
two dimensional materials
• When individuals look at books on tablet then move
to real books.
Occupational Therapy and Physical Therapy
Environmental adaptations using
technology (cont.)
• If distance viewing is difficult and getting close to and
item is not an option ( ie: zoo trip)
• The tablet can be used to bring items at a distance
closer
• Take a picture of items at a distance and show them
on the tablet
• Discuss the features of the item while in the
environment to help with learning
Occupational Therapy and Physical Therapy
Common toys for phase 2
http://www.shutterstock.com/pic-45111304/stock-photo-anorange-toy-plastic-carrot.html
http://cutcaster.com/photo/100733867-Colored-soccer-football-balls/
http://www.film.queensu.ca/Cj3b/ToysMedium.html
Objects with 2-3 colors
http://www.zymetrical.com/bulk-assorted-color-duckies-p-1495.html
Occupational Therapy and Physical Therapy
http://www.antistresstoys.com.au/html/stress_nature.html
Common toys for phase 2
Cause and Effect Toys
Occupational Therapy and Physical Therapy
Common Phase 3 Behaviors
• Difficulty with complexity in 2 dimensional materials
• Difficulty with visual complexity and distance viewing
in unfamiliar indoor and outdoor areas
• Difficulty with specific visual fields (most commonly
lower fields)
• Difficulty with visually guided reach with small
objects or on a complex background
Occupational Therapy and Physical Therapy
Phase 3 Intervention
Goal: Facilitate the resolution of the CVI characteristics that
remain active and affecting function
• Background complexity should be increased over time as the
child is able to identify the salient features or details of the
object
• Boat against black background
• Boat against wave background
• Boat against waves and cloud background
Occupational Therapy and Physical Therapy
Phase 3 Intervention, -cont.• Complexity of the environment should be increased
over time
– The child should eventually be able to find objects
in unfamiliar indoor and outdoor environments
• Difficulty with noticing transitions in the
environment including descending steps, drop offs at
curbs or surface changes.
– These children often work with orientation and
mobility services.
Occupational Therapy and Physical Therapy
Phase 3 Intervention (cont)
• Difficulties with handwriting are common
• Begin with three dimensional materials building
letters using straight lines and curves
• Use the light box to build visual attention
• Templates of the letters can be shown on the
lightbox
• After three dimensional materials are mastered
begin forming with markers
Occupational Therapy and Physical Therapy
Phase 3 Environmental Modification for
Intervention
• Intervention focus on ADL or school task with modifications
for characteristic that is still present
• Example: latency, color to point out salient features of object,
complexity of task or environment.
• New environments are difficult to process and/or to figure out
what to focus visual attention to
• Consider additional practice in new environments to build
familiarity and skills in the new environment
• Use narration regarding what the child should be focusing on
• Ask the child to explain what they are seeing
Occupational Therapy and Physical Therapy
Common toys/activities for phase 3
• Hidden Picture Activities
• Find all of the “e”
• Object discrimination – very different
pictures, similar pictures, etc.
• Letter discrimination
• Locating part of a complex picture
• Locating signs in the environment
• Highlighting salient features of letters,
sight words, etc.
Occupational Therapy and Physical Therapy
Common toys/activities for phase 3, -cont.-
http://www.mydeliciousambiguity.com/2012/01/learnin
g-activities-with-legos.html
https://itunes.apple.com/us/app/colordrops-childrensanimated/id484422403?mt=8
http://www.123rf.com/photo_7290840_ball-ofbrightly-multi-colored-network-cables-isolatedon-white-background-ball-of-of-colouredwires.html
Increase the complexity of toys (by increasing the number of colors within the toy)
Increase the complexity of sign/object location tasks (by increasing the amount of background included)
Occupational Therapy and Physical Therapy
http://bluemoondevotionals.blogspot.com/2010/06/s
top-signs.html
http://www.freefoto.com/preview/41-11-4/One-WayUSA-Road-Sign
Clinical Scenario
Occupational Therapy and Physical Therapy
Take Home Message
• Patients with CVI have the potential to
significantly improve functional vision
• Simple environmental and task modifications
at home and during a therapy session can
make a huge impact on the performance of a
patient with CVI
• Caregiver engagement in therapy is essential
Occupational Therapy and Physical Therapy
Occupational Therapy and Physical Therapy