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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
jenniferhefner@creighton.edu
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 (vanessajewell@creighton.edu)
René Padilla, PhD, OTR/L, FAOTA, Associate Professor of OT and Associate Dean for Academic Affairs
(rpadilla@creighton.edu)
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
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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
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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
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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.
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Adapted from AOTA Evidence-Based Literature Review Project/CAT Worksheet.5-05