Description and measurement of visual scanning training in Occupational Therapy for patients with visual search deficits following stroke

Executive SummaryBackgroundVisual search is a process which is integral for carrying out most activities of daily living; for example for finding utensils needed in preparing a meal or for avoiding hazards when crossing the road. This essential process is commonly disrupted by visual impairments and reduced spatial attention after stroke. Affected individuals can experience long term limitations in everyday activities due to inefficiencies in observation and visual searching. Occupational Therapists working in stroke services include visual scanning and search training within their treatment. However it is not known if the intervention is effective for improving occupational performance and visual functioning. Before the intervention can be properly evaluated for its effectiveness some essential development work is needed AimsThis project aimed to prepare for an evaluation of effectiveness of visual scanning and search training in Occupational Therapy by achieving three important steps: 1.A detailed and systematic description of the intervention delivered in the community setting2.Development and pilot testing of a process measure to quantify search performance in the home context 3.A feasibility study of the intervention delivered intensively over three weeks.MethodsTo obtain a description of the intervention a specialist Occupational Therapist in stroke, working in a community service, made video recordings of her treatment sessions delivered to five participants with visual field deficits after stroke. The recordings were analysed using a framework approach. The findings were presented to a reference group of Occupational Therapists interested in vision after stroke for validation of the description as good clinical practice. A timed room search task using keys placed in different parts of a living room over 16 trials was designed to measure search performance. Point of regard during the searches was recorded from a digital video camera worn on the participant’s head.Feasibility of the defined intervention delivered three times a week for three weeks and of the room search task administered in the home before and after the intervention was tested with nine participants. In addition a patient reported outcome measure, the Visual Functioning Questionnaire (VFQ25), was administered before and after the intervention.Summary of key findings•A detailed description of Occupational Therapy intervention for training visual scanning and search has been developed. The intervention is task specific to participants’ goal occupations and trains strategies for search using remedial activities and real tasks. The intervention was endorsed as good clinical practice by the reference group of Occupational Therapists with special interest and experience in training scanning and search in people with visual impairments after stroke.•The treatment was found to be feasible and acceptable to participants treated intensively over three weeks.•A room search task for assessing search performance proved to be feasible and demonstrated changes in the distribution and starting point of search after the intervention. However these changes in search behaviour did not always lead to increased speed or accuracy. Participants with more severe visual impairments were more efficient in searching after the treatment while some more mildly affected participants took longer to find the object.•A patient reported outcome measure was tested and found to be responsive in the sample suggesting it may be a good primary outcome measure for a clinical trial. The participants reported better visual functioning on the visual functioning questionnaire after the intervention.Recommendations for researchFurther work is needed before the intervention is evaluated in a clinical trial:Some experimental work is needed to determine the efficacy of search strategies used in the intervention. The results from our small sample suggest that strategies should be tailored to individuals’ baseline performance. For example starting the search in the blind field may be helpful in some cases, but a hindrance in others. Further work is needed to identify the most effective strategies for improving search performance in different individuals and to understand the mechanisms of the intervention for improving patients’ perceptions of their visual functioning. A measure of search performance in real world tasks would be helpful to determine the mechanism for improving function, and for understanding which patients benefit. The room search task goes some way towards this, but further work is recommended to investigate the use of new technologies to achieve more flexible and more accurate recording of point of regard during real activities of daily living.The visual functioning questionnaire,(VFQ25) would appear have potential as a primary outcome measure in a trial of clinical effectiveness of the intervention. Further research into its responsiveness and internal consistency in a larger sample of stroke participants is recommended

The contribution of reorganised motor pathways to recovery of arm and hand function after stroke

Stroke often disrupts the descending motor pathways controlling the upper limb with severe consequences for patients' hand function. Although some recover they are often slow and clumsy when using the affected hand. The mechanism underlying recovery is an unsettled question. Transcranial magnetic stimulation (TMS) was used to determine the changes in the connectivity and function of the corticospinal tract (CST) that are associated with improved motor performance in the recovering arm and hand. The study comprised four parts: 1. Task dependency of responses to TMS in recovered stroke patients. Eight patients, who had recovered some degree of hand function were tested for task dependence of short-latency EMG responses to TMS. Normal subjects were also tested. 2. Longitudinal investigation of recovery of voluntary movement of arm and hand after stroke. The relationship between the recovery of hand and arm function in a group of acute stroke patients (n=21) and the presence of short latency contralateral and ipsilateral EMG responses to TMS in four different upper limb muscles was investigated. 3. Ipsilateral responses in normal subjects. The results of the longitudinal study prompted further investigation of the presence of ipsilateral responses in proximal and distal muscles in fifteen normal subjects. 4. The contribution of CS input to production of force in proximal and distal upper limb muscles. Because patients did not always have responses to TMS in recovered proximal muscles, two further studies were carried out to clarify the contribution of CS input to production of force in proximal and distal upper limb muscles. First, the effect of voluntary contraction on response amplitudes in deltoid, biceps and ID1 were compared. Second, the effect of increasing stimulus intensity on recruitment of low threshold motor units was assessed for deltoid and ID1. In addition the change in response amplitude with increasing voluntary activity in the affected and unaffected shoulder muscles of three patients were compared

Pilot study for a randomised controlled trial of home based reach to grasp training for people after stroke: 'Recovery after Stroke' participant information booklets

As part of the 'Reach to Grasp pilot study', information booklets were produced for participants in the intervention and control groups to provide advice about stroke, neuroplasticity and local services

An exploratory randomized controlled trial of assisted practice for improving sit-to-stand in stroke patients in the hospital setting

Objectives: To evaluate the amount of practice achieved and assess potential for effects on performance of 30 minutes of daily training in sit-to-stand. Design: Randomized controlled pilot study. Setting: Stroke rehabilitation unit, UK. Participants: Eighteen stroke patients needing 'stand by' help to sit-to-stand. Interventions: In addition to usual rehabilitation the experimental group (n=9) practised sit-to-stand and leg strengthening exercises for 30 minutes, on weekdays for two weeks, with a physiotherapy assistant. The control group received arm therapy. Main outcome measures: Frequency of sit-to-stands per day. Performance measures: rise time, weight taken through the affected foot at 'thighs off', number of attempts needed to achieve three successful sit-to-stands and the number of sit-to-stands performed in 60 seconds. Outcome was measured one and two weeks after baseline assessment. Results: Sit-to-stand frequency averaged 18 per day. Thirty minutes of practice in sit-to-stand resulted in a mean of 50 (SD 17.2) extra stands per day. There was a significant mean difference of 10% body weight taken through the affected foot after one week of intervention: The control group had reduced weight through the affected leg while the training group increased weight (F1,16 = 11.1, P=0.004, 95% confidence interval (CI) - 16.61 to - 3.72). No significant differences between groups were found on other measures. Results two weeks after baseline were inconclusive due to loss of five participants. Conclusions: Task-specific practice given for 30 minutes a day appears promising for patients learning to sit-to-stand. © SAGE Publications 2008

Exploring altered body perception and comfort after stroke: An interpretive phenomenological analysis

Background: After stroke, changes to body perception are common. However, little is known about what these disturbed perceptions feel like to the stroke survivor. This study took a phenomenological approach to explore experiences ofaltered body perception, whether these perceptions were uncomfortable, and whether participants indicated a need for clinical interventions.Method: A purposive sample of 16 stroke survivors were predominantly recruited from community support groups for stroke. All participants were at least six months post-stroke, experiencing motor and sensory impairments and able to communicate verbally. In-depth, semi-structured interviews were conducted in participants’ homes. Interviews were audio-recorded, transcribed verbatim, and analysed alongside reflexive notes using an interpretativephenomenological approach. Ethical approval was obtained from University of the West of England.Results/Findings: Four themes emerged. Participants described a body which did not exist; a body hindered by strange sensations and distorted perceptions; an uncontrollable body; and a body isolated from health professionals and clinical interventions. Participants expressed discomfort and feelings of conflict towards the body. They found their experiences difficult to understandand hard to describe.Discussion: Altered body perceptions left survivors feeling disembodied: their bodies perceived as strange, uncooperative, uncomfortable, and isolated from support. This is the first study to look at altered body perceptions in terms of patient comfort.Conclusion: These findings highlight the need for health professionals to recognize and support the communication of stroke survivors’ experiences of altered body perceptions and discomfort. Further research is needed to determine new ways to communicate about altered body perception and develop interventions to improve body comfort

Management of hemiplegic shoulder pain: A UK wide online survey of physiotherapy and occupational therapy practice

Introduction:Hemiplegic shoulder pain (HSP) is a common complication of stroke that can lead to reduced quality of life. The primary aim of the present study was to identify how HSP is assessed, diagnosed and managed in routine clinical practice by physiotherapists (PTs) and occupational therapists (OTs) in the UK. A secondary aim was to identify the challenges to services in the management of HSP. MethodsA questionnaire was developed from similar surveys of musculoskeletal/neurological practice, a review of the literature and consultation with researchers and clinicians. The survey was distributed online to PT’s and OT’s working in stroke rehabilitation via professional bodies’ interest groups. Results: Sixty seven responses were received from PTs (60%) and OTs (40%). The respondents gained knowledge in HSP management through in-service training, clinical supervision and reading (80%). HSP was routinely checked (89%) and the mean time spent on assessment was 10 minutes. Commonly used assessments were glenohumeral subluxation (94%), strength (76%), range of movement (67%), spasticity (79%) and palpation (63%). Interventions included education, exercise and self-management. Patients were discharged when treatment options were exhausted (80%). Time constraints (62%); lack of diagnosis (54%) and training (60%) were the major challenges in providing appropriate care for HSP. Conclusion: The results suggest that a wide range of approaches are utilised by clinicians and that patients are potentially receiving treatment irrespective of the underlying problem due to lack of accurate diagnosis of the cause of HSP. A comprehensive assessment tool and additional training specific to HSP are required to improve the patients’ outcome

Evaluation of a prototype tool for communicating body perception disturbances in complex regional pain syndrome

Patients with Complex Regional Pain Syndrome (CRPS) experience distressing changes in body perception. However representing body perception is a challenge. A digital media tool for communicating body perception disturbances was developed. A proof of concept study evaluating the acceptability of the application for patients to communicate their body perception is reported in this methods paper. Thirteen CRPS participants admitted to a 2-week inpatient rehabilitation program used the application in a consultation with a research nurse. Audio recordings were made of the process and a structured questionnaire was administered to capture experiences of using the tool. Participants produced powerful images of disturbances in their body perception. All reported the tool acceptable for communicating their body perception. Participants described the positive impact of now seeing an image they had previously only imagined and could now convey to others. The application has provided a novel way for communicating perceptions that are otherwise difficult to convey

A single blinded randomised controlled pilot trial of prism adaptation for improving self-care in stroke patients with neglect

Prism adaptation has been shown to alleviate the symptoms of unilateral spatial neglect following stroke in single case and small group studies. The purposes of this single blinded pilot randomised controlled trial were to determine the feasibility of delivering prism adaptation treatment in a clinically valid sample and to assess its impact on self-care. Thirty seven right hemisphere stroke patients with unilateral spatial neglect were randomised into either prism adaptation (using 10 dioptre, 6 degree prisms) or sham treatment (using plain glasses) groups. Treatment was delivered each weekday for two weeks. Pointing accuracy, without vision of the finger, was recorded each day before treatment. Outcome was measured, by blinded assessors, four days and eight weeks after the end of treatment using the Catherine Bergego Scale (CBS) and the conventional neuropsychological tests from the Behavioural Inattention Test (BIT). Thirty four patients received treatment: 16 with prisms, 18 sham. Mean compliance was 99% and 97%, respectively. Over the treatment days only the prism treated group showed increased leftward bias in open loop pointing to targets on a touch screen. However, despite the group level changes in pointing behaviour no overall effect of the treatment on self-care or BIT were found. © 2009 Psychology Press

Pilot study for a randomised controlled trial of home based reach to grasp training for people after stroke: Instruction manual for exercise manual

This is the instruction manual for the exercise manual produced to describe the intervention in the 'Reach to Grasp pilot study' as clearly as possible

Pilot study for a randomised controlled trial of home based reach to grasp training for people after stroke: Exercise manual

As part of the 'Reach to Grasp pilot study', an exercise manual was produced to describe the intervention as clearly as possible. An instruction manual describing the intervention is available on the repository also