Visual Rehabilitation: Promoting Sight, Self-Care, Safety & Success May 14, 2015

LINDA CLEMENTE, OTR/L PATRICIA HIGGINS MS, OTR/L

NIDHI SHAH PT, DPT HEALTHSOUTH REHABILITATION HOSPITAL OF TINTON FALLS

BACKGROUND AND INTRODUCTION

PATTI HIGGINS, MS, OTR/L

Vision: One of the Most Important Senses

u  Allows us to gather, process and react to the environment

u  Enables us to plan movements, move within our environment, and maintain an upright position in space.

u  Allows us to accurately attend to environmental information, integrate it, and use it to make daily decisions

u  First system to alert us to DANGER and PLEASURE

.

VISION is used for:

u Decision making-executive functioning

u Social Interactions and facial expressions

u Motor and postural control

u Planning ahead for what the environment presents us with

VISION -> PRIMARY WAY OF ACQUIRING

INFORMATION

u 1/3 to 1/2 of the brain is devoted to pure visual processing

u 90% of sensory input is VISION

“ ”

“Vision dominates the sensory context for the simple reason that it takes us further into the environment than any of the other senses do.”

(Pendleton and Schultz-Krohn, 2012)

Professionals on the Rehabilitation Team

u  Vision rehab is a team effort •  Physiatrist

•  Internal Medicine

•  Nurses

•  Ophthalmologist

•  Neuro-optometrist

•  Occupational Therapist

•  Physical Therapist

•  Speech Therapist

•  Psychologist /Social Worker

ROLE OF OCCUPATIONAL THERAPIST

u  Observe functional activities

u  Perform screening of gross visual function

u  Work closely and collaboratively with the physiatrist and neuro-optometrist

u  Implement vision strategies and interventions as advised by the physician

u  Determine how the vision impairment impacts a persons ability to perform daily tasks

Role of Occupational Therapy – cont’d

u  Modify the task/environment to minimize those limitations

u  Evaluate the environment and provide recommendations as necessary

u  Recommend adaptive devices/assistive technology

u  Provide interventions to improve visual attention, search and speed, and efficiency of visual processing

(American Occupational Therapy Association, 2011)

“ ”

Occupational Therapy focuses on reducing the impact of disability by

promoting independence and participation in valued

activities.

- American Occupational Therapy Association

What OT is NOT:

u  O.T. is NOT visual therapy u  O.T.’s DO NOT diagnose

u  O.T’s DO NOT consider visual deficits without it’s relationship to performance in A.D.L’s

ROLE OF PHYSICAL THERAPY

u  Observe mobility and mobility related activities

u  Perform screening of gross visual function when indicated

u  Work closely and collaboratively with the physiatrist, neuro-optometrist and OT

u  Determine how the vision impairment impacts a persons mobility

u  Assessment of fall risk and fall prevention training

u  Assessing and training for safe environmental navigation in the home and in the community

u  Reintegration of an individual with brain injury and/or visual deficits into the community in a safe, yet independent manner

“ ”

Physical therapists are movement disorder specialists who provide services that help restore function, improve mobility, relieve pain, and prevent or limit permanent physical disabilities in patients with injury or disease.

- American Physical Therapy Association

VISUAL HIERARCHY MODEL

u  Visual acuity needs to be assessed prior to treatment techniques of fixation, scanning, tracking for eye hand

coordination to perform

ADL’s

u  The building block for increased independence

with ADL’s and functional mobility.

Adaption through vision

Visuocognition

Visual memory

Pattern Recognition

Scanning

Attention= Alert and Attending

Oculomotor Control Visual Field

Visual Acuity

vvVVpPsOOCOsasWWWWWW

Warren 2009

VISUAL DEFICITS AFTER BRAIN INJURY

PATTI HIGGINS, MS, OTR/L

VISION AND BRAIN INJURY

u  Greater than 50% of those who suffer from a traumatic brain injury experience visual deficits (Politzer, T. 2015)

u  These deficits include oculomotor dysfunction, accommodative dysfunction, binocular vision dysfunction, visual field deficit, topographic disorientation, and visual processing dysfunction

u  Often times, an individual may not recognize the visual deficit themselves

VISUAL IMPAIRMENT AND BRAIN INJURY

u  The quality and amount of visual input into the brain can be altered. (the acuity can be changed)

u  The brain’s ability to process normal visual input can be altered.

u  BOTH can be altered

u  EITHER WAY………. THERE IS A DECREASE IN THE ABILITY TO USE VISION FOR OCCUPATIONS

COMPLICATIONS OF VISUAL IMPAIRMENTS

u  Difficulty completing VISION DEPENDENT activities

u  READING AND DRIVING

u  Feeding, grooming, dressing are less dependent on vision.

u  Decreased SPEED in completing tasks

u  Errors in decision making when vision is impaired

u  Postural Dysfunction

u  Falls

Behavioral Implications of Visual Impairments

u  Decreased Confidence

u  Increased anxiety and uncertainty in responding to the environment

u  Increased passiveness in decision making

u  Difficulty with tasks in dynamic environments

u  Increased Fear of Falling

u  Community activities are the most challenging:

u  Driving

u  Shopping

u  Working

u  Participation in Sports/Leisure Interests

What do we do? Spontaneous and complete recovery may not occur for many clients

THE KEY IS COMPENSATION

VISION SCREENING

u  Record visual history

u  Observe head posture and eye alignment

u  Always watch what the eyes are doing throughout the screening process

u  If the person wears glasses, be sure he/she has them on during screening process and that they are clean

u  Assess acuity first

u  Perform tasks monocularly and binocularly to ensure most accurate information

Oculomotor Skills

u  Ability of the six muscles of the eye to coordinate movement to move the eyes accurately

u  Includes:

u Pursuits

u Fixation

u Saccades

u Scanning

PURSUITS

u The ability to follow a moving object smoothly and accurately with one eye at a time and both eyes together

u Continuous clear vision of moving objects

SYMPTOMS OF PURSUIT DYSFUNCTION

u  Loss of Target

u  Decreased visual attention span

u  Difficulty crossing midline with the eyes

u  Over/undershooting a target with refixation

u  Difficulty with driving, mobility, sports, etc.

u  Head movement

u  Nystagmus, Jumpiness

FIXATION

u The ability to maintain a “visual hold” on an object while stationary

SYMPTOMS OF FIXATION DYSFUNCTION

u Inability to maintain focus on a target

u Attention Deficits

u Looking away from a task often (which may be interpreted as an inattention

Saccades

u The ability to adjust fixations from one stationary object to another

u Speed and accuracy are important u Skill we use to read

Symptoms of Saccades Dysfunction

u Decreased reading speed and comfort

u Eyes fatigue easily when reading

u Poor attention

u  Losing place or skipping lines when reading

u Difficulty locating objects quickly

Functional Implications of Oculomotor Deficits

u Difficulty Reading and Writing

u Skipping words and lines

u Difficulty with page navigation

u Excessive compensatory head movements

u Decreased attention to detail

u Exhibits jerky eye movements during reading or tracking

Binocular Vision

u  The ability to visually focus on an object with two eyes to create a single clear image

u  Binocular Vision Dysfunction includes:

u  Diplopia (double vision)

u  Convergence Insufficiency

u Convergence – the ability of the eyes to simultaneously turn inward to focus on a near point of vision

Symptoms of Binocular Vision Dysfunction

u  Inability to read or perform close tasks

u  Loss of place when reading

u  Difficulty with depth perception

u  Increased frustration with near tasks

u  Squinting

u  Headaches, nausea

u  Closing one eye

Functional Implications of Diplopia

u  Complaints of double vision, either horizontal or vertical

u  Complaints of blurred or shadowed vision

u  Headaches, eye strain, fatigue

u  Difficulty with accuracy during reaching, grooming tasks, going up/down curbs or stairs

u  Repositioning task to self

u  Covering or closing one eye

Behavioral Implications of Diplopia

u  This interferes with object identification

u Creates visual stress

u Almost always interferes with PARTICIPATION…..avoidance behaviors

Functional Implications of Convergence Insufficiency

u  Losing place when reading or writing

u  Difficulty performing tasks close up

u  Complaints of blurred or double vision when focusing on near targets

u  Eye strain or fatigue when reading

Accomodation

u Process of adjusting and sustaining focus from one distance to another

u Ability to change the focus of the eye so objects at different distances can be seen clearly

u Decreases with age

Symptoms of Accommodation Dysfunction

u Excessive blinking u Headaches, eye strain, and fatigue u Sensitivity to light

Functional Implications of Accommodation Dysfunction

u  Complaints of blurred vision especially during grooming, buttoning, shaving, and makeup

u  Difficulty reading with complaints of the print moving

u  Decreased ability to focus

u  Difficulty when reading at a distance and writing close up

u  Driving difficulty

Visual Perception

u  Ability to see, perceive, and interpret the visual information around us

u  Involves cognitive function as well

u  Visual Motor Integration – eye-hand, eye body coordination

u  Visual Auditory Integration – relate what is seen and heard

u  Visual Memory – remember and recall information that is seen

u  Visual Closure – ability to “fill in the gaps” to complete a visual image

u  Spatial Relationships – knowing where you are in space

u  Figure-Ground Discrimination – discern an object from background

(Politzer, T. 2015)

Visual Perceptual Deficits

u Agnosia

u Figure Ground

u Form Constancy

u Topographical Disorientation

u Depth and Distance Deficits

u Apraxia

u Neglect

u Postural Dysfunction

VISUAL FIELD DEFICITS

LINDA CLEMENTE, OTR/L

Visual Fields/Peripheral Vision

u Ability to focus centrally and continue to see peripherally in all directions.

u The space one sees around them when they look out at the world.

Visual Field Deficit (VFD)

u  May occur due to damage to the eye, optic nerve, or brain

u  VFD is when an area of the visual field is missing

u  Various types: u  Central Scotoma – Missing the central field of vision

u  Quadrantonopsia – Loss of vision in a specific quadrant

u  Homonymous Hemianopsia – Loss of vision from one half of each eye resulting in missing information from one half of the field of vision

(Retrieved from Google images)

Full Visual Field Homonymous Hemianopsia

Central Scotoma Quadrantonopsia

Functional Implications of Visual Field Deficits

u  Difficulty walking – steps/curbs, poor balance, walking along the wall

u  Leaving food on the plate

u  Misreading words, reading slowly

u  Difficulty finding grooming items

u  Missing details

u  Writing off the line

u  Increased time/assistance for dressing

u  Trouble navigating the environment

u  Difficulty driving and shopping in a crowded place

Behavior Changes in Field Deficits

u  Persons will adopt a narrow search pattern confined to the sound side or midline

u  Person will scan VERY slowly towards deficit side—This slows down a person during ADL’s and can affect their ability to navigate through dynamic environments

u  Misses or misidentifies visual detail on the blind side

u  Impaired reading performance

u  Difficulty with tasks that have small detail

Behavior Changes in Visual Field Deficit

u  Reduced monitoring of the hand

u  Impaired grapho-motor skills

u  Difficulty pouring liquids

u  Changes in reading

u  Omissions on the involved side

u  Misidentification of words and numbers

u  Poor page navigation may skip lines

u  Reduced reading accuracy and speed

u  ***** reading is not always involved if the fovea is not

Behavior Changes in Visual Field Deficit

u  Changes in Handwriting***

u  Writing may drift up/down on the line

u  May write on top of other words

u  Positions words incorrectly

u ****This occurs only if the visual field deficit is on the same side as the dominant hand

Functional Changes in Visual Field Deficit

u  Changes in A.D. L. u  This happens in areas that depend on vision to complete u  Requires monitoring of a wide visual field

u  Driving u  Shopping u  Community Events

u  Yard Work u  Meal Preparation u  Financial Management u  Housekeeping

u  Self care

More Behavior Changes in Visual Field Deficit

Changes in Orientation

u  Insufficient visual input to accurately map

u  space on involved side.

u  An inability to scan fast

u  enough to comprehend scene as a whole

Tendency to get lost

u  Tends to avoid independent travel

u  Very uncomfortable navigating alone

u  At risk for injury and bumping into objects

Treatment

u Person must learn to use their remaining vision more effectively to compensate for missing vision

u Environment must support participation

u Compensation/adaptation may be a client’s only option since a visual field deficit might have a permanent impairment

Education

u  Education is a KEY adjunct to intervention.

u  Education assists a client to become aware of location and extent of deficit.

u  Education lets a client know how it has affected their occupational performance

INTERVENTIONS FOR VISUAL SCANNING, FIELD AND ACUITY DEFICITS AFTER A BRAIN INJURY

LINDA CLEMENTE, OTR/L

What is Visual Scanning Therapy?

u  Developing skills to COMPENSATE for spatial bias

and to execute a COMPREHENSVE search

u  Reinforce client takes in visual information in a systematic manner

u  Use language and cognition to REDIRECT search

****can not be successful if client does not have

adequate language and cognition*****

Visual Scanning Activities

u  Initiate search from the left

u  Execute a symmetrical search pattern

u  Execute complete search to the left

u  Observe all visual detail

u  Anticipate all visual input occurring on the left

u  Rapidly dividing/shifting attention between left and right fields

u  ***Make the activities as interactive as possible***

Kim et al 2011

Sample of scanning activities

u  Eye and Head movements to the affected side

u  Use of scan boards

u  Use a flashlight to walk around room toward the affected side

u  Use post its around the room to “find” objects

u  Have patient move eyes toward the deficit. Encourage the patient to become aware of the feel of their eyes when gazing as far as possible toward the deficit.

u  Playing various games like puzzles and cards

u  Use balloon and ball toss to encourage movement into the area of deficit and to attend to space on the deficit side.

Central Field Tasks: Cancellation Sheet

Scanning sheet

Crowded Word Search

Small saccadic

Harte Chart

Occupational Therapy Interventions

u  Reading: Must learn how to use new perceptual span

u  Client has to adapt to the new span

u  Requires PRACTICE, PRACTICE, PRACTICE

u  Important to approach it in small, achievable steps: Pre-reading exercises

u  Read in large print

u  Read desired material

u  Client needs to be successful with letters and words before reading. 20-30 minutes a day is recommended

TECHNOLOGY

u  Dynavision/Light Board

u  Computer Assisted Biofeedback

u  Hand Mentor

u  Laser Pointers

u  IPad

u  Neuro Eye Coach, BITS

u  Internet Websites, computer games, apps

u  Eyecanlearn.com

u  Highlight.com

u  Tacustherapy.com

Goal of Interventions

u  Elicits and increases head turning, width and speed

u  Increases attention/focus to involved side

u  Creates anticipation to the involved side

u  Improves the efficiency of the visual search through repetition

GOAL of THERAPY

The ultimate goal is independence and participation in daily occupations.

In summary:

u  Effective compensation for field deficit

u  Improved search of environment

u  Develop supportive routines and safe habits

LOW VISION

LEGAL BLINDNESS : VISUAL ACUITY WITH BEST CORRECTION IN THE BETTER EYE WORSE THAN OR EQUAL TO 20/200 OR A VISUAL FIELD EXTENT OF LESS THAN 20 DEGREES

LOW VISION: FUNCTIONAL LIMITATIONS THAT HAMPER ENJOYMENT AND PERFORMANCE OF EVERYDAY ACTIVITIES

WWW.NIH.GOV.COM

Definition of Low Vision

u  A visual impairment that can not be corrected by conventional glasses, contact lenses, surgery, or medicine.

u  Eye diseases/Brain injury cause one or more of these symptoms:

u  A loss of ability to see detail (visual acuity)

u  A loss of peripheral vision (visual field)

u  Constant double vision (diplopia)

u  Difficulty navigating steps or curbs (contrast sensitivity)

u  An inability to distinguish colors

General Principles for Enhancing Visual Performance

Increase visibility of the task or the environment

u Make things brighter u Make things bigger u Use contrast to increase visibility

Interventions

u  *****The main principle is to MAGNIFY the image using various tools*****

u  Low vision reading glasses

u  Magnifiers(hand held and stand)

u  Telescopes (hand held or mounted onto glasses)

u  Microscopes (reading lenses)

u  Computer devices( text to speech programs

u  e-books readers (ie. Kindle with larger font/changing contrast screen)

u  Smart phones and tablets

u  Electronic Video Magnifiers (CCTV)

u  Talking watches and clocks

Increase the contrast

Minimize the background Pattern Clean up the clutter Organize similar items/separate colors

Reduce patterns

Minimize background pattern

ORGANIZE u Structuring your physical space helps with

cognitive functioning. u Increased participation if things are

organized. Predictability of the physical space.

u Label things clearly. Use tactile sensory input

Organize

Provide Optimal Lighting

u  Even illumination

u  Minimize glare

u  Flexible placement: aim for even illumination and brightness

u  Task lighting

u  Carry a penlight

Increase the

brightness

Types of lighting

u  Fluorescent Lighting: even illumination, but limited placement flexibility

u  ( pulsing light bothers some people)

u  Halogen Lighting: high quality light minimum glare, but is “hot light”

u  LED Lighting: Instant on, high intensity, low glare

u  Simulated daylight light: increases contrast, increases clarity, low energy

Glare

MANAGE GLARE SENSITIVITY

u Reduce glare sources

u Use proper window covering

u Cover reflective surfaces( floors,shiny counter)

u Use filters to control incoming light(wear clip on or fit over glasses, visor may be helpful)

Cover surfaces to reduce the glare

Enlarge- make things bigger

u  Enlarge with contrast u  ie. Large button calculator

u  Large button remote

u  Large print cards, bingo

u  Move in closer u  ie. Sit closer

u  Magnify: u  electronic magnification devices

u  hand held or stand magnifiers

Summary

u  Rehabilitation therapists encourage patients to make the most of their remaining vision.

u  Occupational Therapists can educate patients in understanding the neurological component of visual field loss, contrast, glare and lighting needs.

u  Occupational Therapists are trained in incorporating compensatory and adaptive techniques.

u  Occupational Therapists use the building blocks of the visual hierarchy model for achieving success and increased independence with A.D.L.’s, functional mobility, and SAFETY!

VISION AND MOBILITY NIDHI SHAH, PT, DPT

VISUAL IMPAIRMENTS AFFECT MOBILITY, ORIENTATION AND GAIT

u  Hesitation, Anxiety during all mobility related tasks

u  Person prefers to follow vs lead

u  Person exhibits an uncertain gait – difficulty following the appropriate path, disorientation to vertical and to the surroundings

u  Person tends to watch their feet and trails arms with ambulation

u  Comes very close to obstacles and stops often to search

u  All this in conjunction with reduced attention to task, and/or inattention to one side often leads to falls

u  Sometimes complicated by physical impairments that may have occurred with a brain injury (limb weakness, hemiparesis, contractures or spasticity)

HOW VISUAL DEFICITS AFFECT POSTURE AND ORIENTATION

Karnath et al, 2003

BALANCE AND FALL RISK ASSESSMENT

u  Assess reliance on vision for balance u  Clinical Tests of Sensory Integration and Balance

u  Assess fall risk using appropriate clinical testing u  Timed Up and Go test u  Berg Balance test

u  Postural assessment –visual field deficits and other visual perceptual deficits alter the person’s perception of vertical and force postural change u  Assess posture in different positions (bed, wheelchair, standing) from

different planes

u  Posturography to assess center of gravity displacement in different postures on varying surfaces

INTERVENTIONS TO IMPROVE BALANCE AND REDUCE FALL RISK

u  Static sitting and standing training to improve postural stability

u  Dynamic training that challenges stability, explore stability limits in different environments, on different surfaces

u  Reduce reliance on vision for balance, enhance somatosensory and vestibular inputs for balance

u  Improve posture in different positions using tactile, visual and somatosensory feedback

u  Performance and task practice to promote a sense of independence

u  Assess home and proximities to recommend changes and ensure safety - Balliet et al, 1987, Brown et al 1987, Gill-Body et al 1997, Stoykov et al, 2005, Freund and Stetts, 2010

INTERVENTIONS TO IMPROVE BALANCE AND REDUCE FALL RISK

- Bastian et al, 1997

GAIT ASSESSMENT

u  Observational assessment

u  Video assessment (HIPPAA!)

u  Clinical testing u  Functional Gait Assessment

u  Gait speed testing

u  Two minute walk test

u  Other timed tests

INTERVENTIONS TO IMPROVE LOCOMOTION

u  Assess and recommend appropriate assistive device

u  Train to improve gait in the following ways u  Open environments

u  Around & over fixed obstacles

u  Sudden change in direction

u  Head turns while walking

u  Change in speed

u  Different surfaces and changing surfaces

Jeka et al, 1997;

FUNCTIONAL MOBILITY ASSESSMENT

u  Includes mobility like transfers to the bed, toilet or shower, walking to the closet to retrieve clothes for dressing, etc.

u  Involves assessment of patient performance of transfer, % assistance needed and possible safety considerations

u  Barthel Index

u  Functional Independence Measure

u  Consider other physical impairments as well

INTERVENTIONS FOR FUNCTIONAL MOBILITY

The Desired Compensatory Behaviors: u  Using the appropriate assistive

device u  Using the recommended

adaptive equipment u  Wider head turn

u  Increased head movement in anticipatory behavior

u  Faster head movement to compensate for possible lack of scanning or field

The Desired Remediation in Behaviors:

u  Improved sequencing to complete functional mobility

u  Improved motor planning

u  Improved posture and improve orientation to vertical

u  Organized, efficient search pattern

u  Increased attention to visual detail

u  Improved patient understanding of their deficits

VISUAL CHANGES AFFECT ORIENTATION

u  Insufficient visual input to accurately map space on involved side. An inability to scan fast enough to comprehend scene as a whole

u  Tendency to get lost

u  Tends to avoid independent travel

u  Very uncomfortable navigating alone

Scanning Routes

*Starting to incorporate scanning into movement

*Teach a client to consciously observe environment during ambulation tasks

*Begin with activities in the gym/clinic

a. Scan courses

b. “Find a color”

c. Narrated walk

d. Treasure hunts: incorporate language, memory, executive functioning

OBSTACLE AND SCANNING ROUTES

A simplified sketch of an obstacle course used in schools, can be adapted for adults with brain injury to train for orientation and mobility

Education is a KEY adjunct to intervention

!  Education assists a client to become aware of location and extent of deficit.

!  Education lets a client know how it has affected their occupational performance.

!  A lack of this awareness could be hazardous to the patient’s safety.

!  Education about safety with the use of recommended assistive device, and why it is needed.

!  Education about possible changes to be made in the home/ proximity to ensure patient safety

Education is a KEY adjunct to intervention

u  Education of the caregiver is as essential as educating the patient

u  Assess the patient (& caregiver’s) health literacy,

u  Assess appropriate learning mode. Remember that for a person with a brain injury affecting vision, reading material might not be the most appropriate learning mode, use auditory information instead

u  UTILIZE TEACHBACK to assess patient understanding

FINAL THOUGHTS TO ADDRESS MOBILITY

u  If possible progress to outside/community environments. It is critical to educate clients about potentially dangerous situations.

u  ALWAYS link clinic activities with the outside world to make them more meaningful

u  ALWAYS increase visibility, think about good contrast, create the best illumination, and minimize the pattern. Organized and structured environment

u  Therapy should create context that support participation

u  ALL THERAPY MUST BE GOAL ORIENTED

REFERENCES Balliet et al. (1987) Retraining of functional gait through the reduction of upper extremity weight bearing in chronic cerebellar ataxia. International Rehabilitation Medicine, 8, 148-153.

Bastian AJ. Mechanisms of ataxia. Phys Ther. 1997;77:672-675.

Bateni et al. (2004) Can use of walkers or canes impede lateral compensatory stepping movements? Gait and Posture, 20, 74-83.

Bynum H, Rogers J (1987) The Use and Effectiveness of Assistive Devices Possessed by Patients Seen in home care. American Occupational Therapy Journal 7: 181-184

Carlton RS (1987) The effects of body mechanics instruction on work performance. American Journal of Occupational Therapy 41: 16-20

Ciuffreda ,K., Rutner ,D,. Kappoor, N., Suchoff, I, Craig, S & Han,ME(2007) . Occurrence of oculomotor dysfunction in acquired brain injury. A retrospective analysis. Optometry,78,155-161.

Cohen, JM.(1992) An overview of enhancement techniques for peripheral field loss. Journal American Optometric Association, 63,60-70.

Geiger CM (1989) the utilisation of assistive devices by patients post discharges from an acute rehabilitation setting. Unpublished Masters Thesis. Temple University

Jeka JJ (1997) Light touch contact as a balance aid. Physical Therapy, 77, 5, 476-487.

Katz, Noomi; Hartman-Maeir, Adina; Ring, Haim; Soroker, Nachim, "Functional disability and rehabilitation outcome in right hemisphere damaged patients with and without unilateral spatial neglect." Archives of Physical Medicine & Rehabilitation 80.4 (1999) 379-384 Markowitz, Michelle, "Occupational Therapy Interventions in Low Vision Rehabilitation" Canadian Journal of Opthalmology 41. 3 (2006): 340-347. Mennem ,T.A., Warren, M., Yuen, H.K.(2012) Preliminary validation of a vision dependent activities of daily living instrument on adults with homonymous hemianopsia. American Journal of Occupational Therapy, 64(4) 478-48. Ponsford, Jennie. "Rehabilitation Interventions after mild head injury." Current Opinion in Neurology 18. 6 (2005): 692 - 697. Pambakian,A.L., Currie, J & Kennard,C. (2005) Rehabilitation strategies for patients with homonymous visual field deficits. Journal of Neuro-Ophthalmology, 25, 136-142. Pendleton and Schultz-Krohn. (2012). Pedretti’s Occupational Therapy: Practice Skills for Physical Dysfunction, 7th edition. Mosby. Politzer, T. (2015, April 22) Introduction to Vision and Brain Injury. Retrieved from Neuro-Optometric Rehabilitation Association website https://nora.cc/for-patients-mainmenu-34/vision-a-brain-injury-mainmenu-64.html

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