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MeSH TERMS OBJECTIVE. Visual and visualperceptual impairments occur frequently with traumatic brain injury (TBI)
brain injuries and influence occupational performance. This systematic review examined the effectiveness of interventions
within the scope of occupational therapy to improve occupational performance for adults with visual and
cognitive therapy
visualperceptual impairments as a result of TBI.
occupational therapy
METHOD. Medline, PsycINFO, CINAHL, OTseeker, and the Cochrane Database of Systematic Reviews were
photic stimulation
searched, and 66 full text articles were reviewed. Sixteen articles were included in the review.
vision disorders
RESULTS. Strong evidence supports the use of scanning, limited evidence supports the use of adaptive strat-
visual perception egies, and mixed evidence supports the use of cognitive interventions to improve occupational performance for
adults with TBI. Evidence related to vision therapy varies on the basis of the specific intervention implemented.
CONCLUSION. Although the strength of the research varied, implications are discussed for practice,
education, and research.
Berger, S., Kaldenberg, J., Selmane, R., & Carlo, S. (2016). Effectiveness of interventions to address visual and visual
perceptual impairments to improve occupational performance in adults with traumatic brain injury: A systematic
review. American Journal of Occupational Therapy, 70, 7003180010. http://dx.doi.org/10.5014/ajot.2016.020875
supports the use of Fresnel 40-diopter prisms to improve Vision Therapy for Visual Field Deficits. Visual restorative
visual field awareness and functional mobility (Giorgi, therapies (VRTs), a subset of vision therapy, are remedial
Woods, & Peli, 2009). Self-reported improvements were interventions that attempt to stimulate the impaired visual
noted in perceived quality of life, visual field awareness, field by introducing lights, letters, or objects randomly
walking, negotiation in crowds, and obstacle avoidance. outside the intact field of view. Evidence to support the
Limited evidence from 1 Level II study supports the use use of VRTs to improve visual search skills is insufficient
of scrolling text to improve reading performance for (Roth et al., 2009, Level I). The evidence is also in-
people with reading difficulties resulting from hemianopsia sufficient to support using VRTs to improve visual field
(Spitzyna et al., 2007). Spitzyna and colleagues found that deficits (Bouwmeester et al., 2007, Level I systematic
scrolling text right to left improved reading saccades and review; Cicerone et al., 2011, Level I systematic review;
reading speed after 4 wk of daily sessions. Roth et al., 2009, Level I RCT). A Level I systematic
review reported that available studies had too many
Vision Therapy critical limitations to make any definitive recommenda-
Vision therapy typically refers to a structured form of vi- tions (Bouwmeester et al., 2007), whereas another found
sual exercise determined in collaboration with an eye care some subjective evidence of improvement with VRTs for
specialist. reading and visual function (Cicerone et al., 2011).
Vision Therapy for Oculomotor Dysfunction. Limited Audiovisual Stimulation for Visual Field Deficits or
evidence from 1 Level II study and 1 Level III study Oculomotor Symptoms. Audiovisual stimulation (AVT)
supports the use of vision therapy to remediate oculomotor consists of scanning training in which a visual stimulus,
signs and symptoms in people with TBI (Alvarez et al., typically illumination of light-emitting diodes, is pre-
2010, Level II; Ciuffreda et al., 2008, Level III). Evidence sented accompanied by a white noise auditory stimulus.
to support the use of vision therapy as a means to facilitate Moderate evidence from 1 Level I RCT and 2 Level II
change in cortical activity, as measured by functional MRI, studies supports AVT as being more effective in im-
in relation to visual function is insufficient (Alvarez et al., proving visual exploration and reading performance in
2010, Level II). people with visual field deficits or oculomotor symptoms
Bornhofen & Mcdonald Level I Intervention condition: Graduated practice of Facial expression naming task Significant gains were noted in two areas: (1)
(2008) increasingly complex tasks of judging emotions Facial expression matching task judging dynamic cues related to basic emotions
RCT with wait list on the basis of context, static visual cues Awareness of Social Inference Test Parts and (2) judging situational cues and determining
N 5 11 adults with severe TBI and (photographs), dynamic visual cues (video 1, 2, and 3 whether the person was lying or being sarcastic or
deficits in emotion processing. vignettes), and situational cues in groups of Sydney Psychosocial Reintegration Scale sincere.
23 with 1 therapist; intervention included
Intervention group, n 5 5 (M age 5 group activities, notebook maintenance, and No significant gains were made in judging static
29.2). cues.
home practice tasks (1.5-hr sessions 2/wk
over 8 wk)
Wait list group, n 5 6 (M age = 43.5).
Control condition: Wait list
The American Journal of Occupational Therapy, May/June 2016, Volume 70, Number 3
Bouwmeester, Heutink, & Level I Visual search strategies or VRT Visual field size No evidence was found that restoration is
Lucas (2007) Visual search field better than compensation. For now, visual
Systematic review
Reading time and error search is recommended because it is simpler
N 5 14 studies (2 RCTs and 12 RMDs; Visual scanning and more user friendly and may provide more
2 RCTs and 5 RMDs describing Subjective measures and questionnaires successful results (or at least as successful
effects of VRT, 7 RMDs describing as VRT).
effects of scanning compensatory
therapy).
Participants: People with HVFDs after
postchiasmatic lesion
1
Supplemental Table 1. Evidence for the Effectiveness of Interventions to Improve Vision and VisualPerceptual Impairments and Skills of People With Traumatic Brain Injury (cont. )
Author/Year Level/Design/Participants Intervention Outcome Measures Results
Cicerone et al. (2011) Level I VRT to address visual field deficits Visual function Some evidence was provided that VRT
Reading speed improved visual function and reading speed.
Systematic review Findings were inconclusive regarding whether
N 5 112 studies related to vision VRT improved visual field or whether change
(5 Level III). was attributable to compensatory strategies as
well (cueing attention). VRT is recommended
Participants: Primarily adults with stroke as a practice option.
or TBI
Ciuffreda, Han, Kapoor, & Level II Versional oculomotor training using computer- Fixation, saccade, pursuit Significant improvement was noted in objective
Ficarra (2006) controlled stimuli (Visagraph) encompassing Simulated reading and subjective reading, but only in 5
Crossover experimental fixation, saccade, pursuit, and simulated reading; Subjective reading rating scale questionnaire participants; in 4 participants, reading remained
N 5 14 adults (9 with mild TBI, 5 with at Week 4, oculomotor auditory feedback related Simulated reading saccade ratio unchanged (improvement was shown in both
stroke) assigned to training method in to eye position added or deleted (1 hr 2/wk over Visagraph groups but was greater with combined vision
counterbalanced manner, separately for 8 wk) and auditory). Other outcomes also
those with TBI and those with stroke demonstrated significant improvement that
(9 men, 5 women; M age 5 48.4). remained at 3 mo.
Ciuffreda et al. (2008) Level III Conventional optometric vision therapy: Marked improvement or normalization of at Of the participants with TBI, 30 (90%) showed
vergence, version, and accommodative therapy least 1 primary symptom (from self-report) complete or marked improvement in 1 or more
Retrospective study and at least 1 primary sign (clinical sign, of their primary symptoms, and 27 (90%)
N 5 40, 33 with TBI, 7 with stroke (M age optometric test) showed improvement or normalization in 1 or
of those with TBI 5 42.3 [3 age 11, all more of their primary clinical signs.
others age 18]).
The American Journal of Occupational Therapy, May/June 2016, Volume 70, Number 3
Giorgi, Woods, & Peli Level III Use of a 40-diopter Fresnel Press-On prism in the Bells Test 14 participants (67%) chose to continue
(2009) superior and inferior position of the glasses Line bisection test wearing the glasses; 5 participants (42%)
1 group, nonrandomized, beforeafter (upper prism placed at Visit 2, lower prism Goldmann kinetic perimetry continued to wear the glasses at the long-term
N 5 23, 2 with TBI, 16 with stroke, 4 with segment at Visit 3). Participants were directed to Visual Function Questionnaire follow-up.
brain tumor resection, 1 with congenital make a vertical head movement so that an object
Visual field expansion of 22 in the upper and
hemianopsia (14 men, 9 women; M of interest detected with the prism segment was
viewed through the central portion of the lower quadrants was seen in all participants.
age 5 46); 19 completed study.
spectacle lens. At Visit 2, the researcher assessed 2 participants had a transient adaptation to the
change in visual directions. Participants
peripheral visual field awareness with a
prism-reaching task on the hemianopic side, perceived significantly reduced difficulty
then walked the participant through the noticing obstacles in the hemianopic side, with
environment observing obstacles. The the potential to increase quality of life.
participant was instructed in 2 brief training tasks
to be performed at home at least 2/day. Visit 3
was similar to Visit 2 but for lower prism
segment. (5 visits over a mean of 9 wk, range 5
513 wk)
(Continued)
2
Supplemental Table 1. Evidence for the Effectiveness of Interventions to Improve Vision and VisualPerceptual Impairments and Skills of People With Traumatic Brain Injury (cont. )
Author/Year Level/Design/Participants Intervention Outcome Measures Results
Keller & Lefin-Rank Level I Intervention group: AVT: Participants looked into Eye movements (e.g., saccades) Significant improvements were noted for AVT
(2010) the center of an apparatus that delivered visual Visual exploration test (computer based) compared with visual training in all measures;
RCT, 2 groups, pretestposttest stimuli to the blind visual field and intact visual Reading test (speed) some of the outcomes for vision alone were
N 5 20 adults with hemianopsia or field in random sequence. Participants had to Search task (objects on board) significant, but results were always better with
quadrantanopsia, 18 with stroke, 1 with detect the presence of visual targets and press a ADLs (evaluated by OT): finding objects, audio and visual combined.
tumor, 1 with TBI (M age 5 59.15); all button as quickly as possible. Study used 20% avoiding bumping into objects, eye contact,
had suffered unilateral lesions of the catch trials with solely acoustic stimulation; seeing obstacles, and reading
occipital lobes 224 wk before whenever the participant responded to a catch Electro-oculography
intervention. trial, a computerized noise sounded. Intervention
occurred in an inpatient rehabilitation setting. (20
Intervention group, n 5 10. 30-min sessions over 3 wk)
Control group, n 5 10. Control group: Visual stimulation training: Same
intervention, but sound was turned off and catch
trials were not needed.
Laatsch & Krisky (2006) Level II Intervention group: Cognitive rehabilitation fMRI Participants demonstrated significant
therapy along with visual scanning, vision Performance Intelligence Scale improvements on 2 neuropsychological
Pretestposttest
perception, attention, verbal fluency, and reading Picture Completion subtest measures between pre- and posttest indicated
N 5 6 adults. on the basis of participants strengths and Visual attention and scanning, Trails A by t scores (1 SD).
weaknesses. Intervention included systematic, and B
Intervention group, n 5 3 with TBI repeated presentation of graded-difficulty Digit Vigilance Test
(M age 5 40). computerized tasks (to address visual processing Iowa-Chapman Reading Test
deficits) and noncomputerized tasks (to address Controlled Oral Word Association Test
Control group, n 5 3 (M age 5 35.7).
visual processing, visual perception, visual Wide Range Achievement Test
scanning, and reading) and included both clinic
and home tasks. All participants were asked to
The American Journal of Occupational Therapy, May/June 2016, Volume 70, Number 3
read aloud for 2030 min/day and complete word
searches at home. (1-hr weekly cognitive
rehabilitation therapy over 711 mo depending
on participant progress)
Lane, Smith, Ellison, & Level II Intervention Group A: Exploration training Perimetry Exploration training did not lead to a greater
Schenk (2010) Find-the-number visual search increase in visual field than attention training.
2 groups, nonrandomized, Intervention Group B: Attention and exploration
Projected visual search
pretestposttest training Visuomotor search Exploration training led to significant improvements
Reading in visual search, but attention training did not.
N 5 42, 4 with TBI. Both interventions used software on a laptop
computer that encouraged visual search and took Visual impairments questionnaire No significant differences in projected visual
Intervention Group A, n 5 21 (16 men, place in 15 sessions, 288 trials/session (9 tasks search were found between groups; within-
5 women; M age 5 65.3).
in 32 trials), mean duration of exploration training subject attention training was more beneficial
Intervention Group B, n 5 21 (15 men, 5 4 wk at z40 min/session; mean duration of than exploration training.
6 women; M age 5 57.1). attention training 5 3.5 wk at z30 min/session.
No significant difference in visuomotor search
was found between exploration training and
attention training.
(Continued)
3
Supplemental Table 1. Evidence for the Effectiveness of Interventions to Improve Vision and VisualPerceptual Impairments and Skills of People With Traumatic Brain Injury (cont. )
Author/Year Level/Design/Participants Intervention Outcome Measures Results
Neither intervention had a significant effect on
reading performance.
Reading was the only item on the visual
impairments questionnaire that showed
significant improvement after exploration
training.
McDonald et al. (2008) Level I Intervention group: Social skills training (social Social perception: Awareness of Social No significant change in social perception was
perception portion used same protocol as in Inference Test (3 scales tested using found.
RCT
Bornhofen & Mcdonald, 2008) with gradually video vignettes: ability to name basic
N 5 39 people with severe TBI from more complex tasks focusing on recognizing emotions, ability to interpret comments,
Australia >1 yr postinjury. specific features. Speechlanguage pathologists ability to determine whether the person is
or psychologists ran each group. Intervention lying or not, sarcastic or not)
Intervention group, n 5 13 (10 men, occurred in hospital outpatient and community Social skills assessments
3 women; M age 5 35.5). facilities. (3-hr sessions 1/wk over 12 wk.)
Control Group 1, n 5 13 (8 men, Control Group 1: Social activity only (placebo)
5 women; M age 5 34.3).
Control Group 2: Wait list (deferred)
Control Group 2, n 5 13 (10 men,
3 women; M age 5 35.3).
Passamonti, Bertini, & Level II Intervention group: Control visual training and Visual field testing No improvement in actual restoration of visual
Ladavas (2009) subsequent audiovisual training consisting of Triangle test field was found. Improvements were noted in
Pretestposttest visual scanning and visual scanning with auditory ADL assessment visual detection and perceptual sensitivity, ADL
N 5 24 right-handed adults. stimulation (4 hr/day over 2 wk) Eye movement performance, visual search, and reading.
Number test
The American Journal of Occupational Therapy, May/June 2016, Volume 70, Number 3
Intervention group, n 5 12 with chronic Control group: No intervention
hemianopsia, 3 with TBI, 9 with stroke
(9 men, 3 women; M age 5 42.67).
Control group, n 5 12 healthy
participants (M age 5 40).
Powell, Letson, Davidoff, Level II Intervention group: Training in the following Recognition of target faces measuring No significant change between groups was
Valentine, & Greenwood strategies using 4 sets of 10 photographs of accuracy of recognition at end of training found in visual processing (p 5 .06).
(2008) Pretestposttest, nonrandomized faces: semantic association, caricaturing, part protocol
controlled (cohort) A significant change in correlation with
recognition, and simple exposure; order was Visual processing: Ravens Coloured
counterbalanced (4 sessions over 2 wk) Progressive Matrices recognition was found after 6 trials of simple
N 5 32 adults with brain injury. exposure (p < .05).
Labeling of facial expression
Intervention group, n 5 20 Control group: Simple exposure: Presentation of Position Discrimination Test from the
a set of faces using the same basic protocol but Semantic association, caricaturing, and part
(M age 5 40.3). Visual Object and Space Perception
with no further elaboration recognition all significantly enhanced
Battery recognition of faces unfamiliar to participants
Control group, n 5 12 (M age 5 46.1).
Unusual Views Test before training.
Letter cancellation
(Continued)
4
Supplemental Table 1. Evidence for the Effectiveness of Interventions to Improve Vision and VisualPerceptual Impairments and Skills of People With Traumatic Brain Injury (cont. )
Author/Year Level/Design/Participants Intervention Outcome Measures Results
Radice-Neumann, Zupan, Level I Intervention Group 1: FAR using computer Facial affect FAR produced significant improvements in
Tomita, & Willer (2009) program of photos and feedback to address facial Vocal affect recognizing facial features, inferring emotions
RCT
feature processing (Part 1) and identification of Emotion evaluation test from context and socioemotional behavior, and
N 5 19 adults with ABI. own internal emotions (Part 2). Emotional inference from context transferring learning to daily settings.
Socioemotional behavior (caregiver
Intervention Group 1, n 5 10 (8 men, Intervention Group 2: SEI using Social Stories on questionnaire) SEI produced fewer improvements than FAR;
2 women; M age 5 47). a computer (visual and auditory) relating to improvements were found 2 wk posttraining in
participants own experiences, how they would participants ability to infer how they would feel
Intervention Group 2, n 5 9 (6 men, have felt, and so forth. in a specific situation.
3 women; M age 5 38).
All interventions occurred 1:1 in a private room in Results suggest that people with brain injury
a hospital (3/wk for 1 hr over 23 wk; 69 hr total can relearn affect recognition skills.
depending on participants learning capacity)
Roth et al. (2009) Level I Intervention Group 1: EST saccadic search task Digit search task identical to EST practice Differences were found between groups
aimed at improving search in the blind hemifield but in structured manner with head stable (favoring EST) for all outcome measures except
RCT (2 groups)
using computer software in home setting (30 Natural search task reading speed and visual fields (perimetry).
N 5 30, 24 with hemianopsia, 6 with min/day, 5 days/wk over 6 wk) Eye fixation stability during natural scene
exploration The EST group demonstrated translation to
quadrantanopsia, 1 with TBI; 2 dropped
Intervention Group 2: FT to improve sensitivity of Perimetry functional activities, specifically social domain
out from FT group, so final N 5 28. the blind hemifield, not to foster exploratory eye (e.g., they found it easier to notice people).
Reading speed
Intervention Group 1, n 5 15 (11 men, movements, using computer software in home Vision-related quality of life questionnaire
4 women; M age 5 60.47). setting (30 min/day, 5 days/wk over 6 wk)
Spitzyna et al. (2007) Level II Intervention Group 1: Practice in reading moving Eye movement recordings Group 1 showed significant improvements in
The American Journal of Occupational Therapy, May/June 2016, Volume 70, Number 3
text that scrolled from right to left (1/day for 2 Reading speed static text reading speed over both therapy
2 group, 2-armed crossover 4-wk blocks) Visual perimetry blocks (18% improvement).
N 5 19 adults with right homonymous Wechsler Abbreviated Scale of Intelligence
Intervention Group 2: Sham therapy (spot the Test of visuospatial function Group 2 did not significantly improve over the
hemianopsia that interfered with reading. difference) for the 1st block and then crossover first block (5% improvement) but improved
Visual Object and Space Perception Battery
Intervention Group 1, n 5 11 (6 men, to moving text for the 2nd (20 sessions of 20 min Graded test of spelling at crossover to the moving text block
5 women; M age 5 49.73). over 4 wk) (23% improvement).
Warrington Recognition Memory Test for
words and faces Moving text therapy was associated with a
Intervention Group 2, n 5 8 (7 men,
1 woman; M age 5 65.13). significant effect on saccadic amplitude for
rightward but not leftward reading saccades.
Note. ABI 5 acquired brain injury; ADL 5 activity of daily living; AVT 5 audiovisual stimulation training; CISS 5 Convergence Insufficiency Symptom Survey; EST 5 explorative saccade training; FAR 5 facial affect
recognition; fMRI 5 functional MRI; FT 5 flicker stimulation training; HVFD 5 homonymous visual field defects; M 5 mean; NPC 5 near point convergence; OT 5 occupational therapist; RCT 5 randomized controlled trial;
RMD 5 repeated-measures design; RPC 5 recovery point of convergence; SD 5 standard deviation; SEI 5 stories of emotional inference; TBI 5 traumatic brain injury; VRT 5 vision restoration therapy.
This table is a product of AOTAs Evidence-Based Practice Project and the American Journal of Occupational Therapy. Copyright 2016 by the American Occupational Therapy Association. It may be freely reproduced for
personal use in clinical or educational settings as long as the source is cited. All other uses require written permission from the American Occupational Therapy Association. To apply, visit http://www.copyright.com.
Suggested citation: Berger, S., Kaldenberg, J., Selmane, R., & Carlo, S. (2016). Effectiveness of interventions to address visual and visualperceptual impairments to improve occupational performance in adults with traumatic
brain injury: A systematic review (Suppl. Table 1). American Journal of Occupational Therapy, 70, 7003180010. http://dx.doi.org/10.5014/ajot.2016.020875
5
Supplemental Table 2. Risk of Bias for Studies Included in the Review (Except Systematic Reviews)
Selection Bias
Patient-Reported Outcomes: Incomplete Outcome Data (Attrition Bias)
Random Sequence Allocation Blinding of Participants and Personnel Blinding of Outcome Selective Reporting
Citation Generation Concealment (Performance Bias) Assessment (Detection Bias) Short Term (26 wk) Long Term (>6 wk) (Reporting Bias)
Alvarez et al. (2010) 1 1 1
Bornhofen & Mcdonald (2008) 1 1 1 1 NA 1
Ciuffreda, Han, Kapoor, & ? 1 1 NA 1
Ficarra (2006)
Ciuffreda et al. (2008) ? ? 1 1 1
Giorgi, Woods, & Peli (2009) 1 1 1
Keller & Lefin-Rank (2010) 1 ? 1 1 1 NA 1
Laatsh & Krisky (2006) 1 ? 1 NA 1
Lane, Smith, Ellison, & 1 1 1 NA 1
Schenk (2010)
McDonald et al. (2008) 1 1 1 1 1 NA 1
Passamonti, Bertini, & 1 1 1 1 1
Ladavas (2009)
Powell, Letson, Davidoff, 1 1 1 NA 1
Valentine, & Greenwood (2008)
Radice-Neumann, Zupan, 1 ? 1 ? 1 NA 1
Tomita, & Willer (2009)
Roth et al. (2009) ? ? 1 ? 1 NA 1
Spitzyna et al. (2007) 1 1 1 1 1
Note. Categories for risk of bias: 1 5 low risk of bias; ? 5 unclear risk of bias; 5 high risk of bias. NA 5 not applicable.
The American Journal of Occupational Therapy, May/June 2016, Volume 70, Number 3
Table format adapted from Assessing Risk of Bias in Included Studies, by J. P. T. Higgins, D. G. Altman, and J. A. C. Sterne, in Cochrane Handbook for Systematic Reviews of Interventions (Version 5.1.0, Chapter 8), by
J. P. T. Higgins and S. Green (Eds.), 2011, London: Cochrane Collaboration. Retrieved from http://www.cochrane-handbook.org. Copyright 2011 by The Cochrane Collaboration.
Suggested citation: Berger, S., Kaldenberg, J., Selmane, R., & Carlo, S. (2016). Effectiveness of interventions to address visual and visualperceptual impairments to improve occupational performance in adults with traumatic
brain injury: A systematic review (Suppl. Table 2). American Journal of Occupational Therapy, 70, 7003180010. http://dx.doi.org/10.5014/ajot.2016.020875
6
Supplemental Table 3. Risk of Bias for Systematic Reviews Included in the Review
A Priori Duplicate Study Comprehensive Status of Publi- List of Included/ Characteristics of Quality of Studies Quality Assess- Methods Used to Likelihood of Conflict of
Design Selection/Data Literature Search cation as In- Excluded Studies Included Studies Assessed and ment Used Combine Results Publication Bias Interest
Citation Included? Extraction? Performed? clusion Criteria? Provided? Provided? Documented? Appropriately? Appropriate? Assessed? Stated?
Bouwmeester, 1 1 1 1 1 1 1 ?
Heutink, &
Lucas (2007)
Cicerone et al. 1 1 1 1 1
(2011)
Note. Responses to risk of bias questions: 1 5 low risk of bias; ? 5 unclear risk of bias; 5 high risk of bias. NA 5 not applicable.
Table format adapted from Development of AMSTAR: A Measurement Tool to Assess the Methodological Quality of Systematic Reviews, by B. J. Shea, J. M. Grimshaw, G. A. Wells, M. Boers, N. Andersson, C. Hamel, . . .
L. M. Bouter, 2007, BMC Medical Research Methodology, 7, p. 10.
Suggested citation: Berger, S., Kaldenberg, J., Selmane, R., & Carlo, S. (2016). Effectiveness of interventions to address visual and visualperceptual impairments to improve occupational performance in adults with traumatic
brain injury: A systematic review (Suppl. Table 3). American Journal of Occupational Therapy, 70, 7003180010. http://dx.doi.org/10.5014/ajot.2016.020875
The American Journal of Occupational Therapy, May/June 2016, Volume 70, Number 3
7
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