Assessment And Intervention Of Visual Perception And .

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Assessment andInterventionofVisualPerception and Cognition FollowingBrain InjuryandtheImpactonEverydayFunctioning.Kara Christy, MS, OTRL, CBISNatasha Huffine, MS, OTRL, CBIS

Vision and the Brain Occipital Lobe Primary visual cortex Visual association cortex Analyzing orientation, position, andmovement. Initiation of Smooth Pursuit Movements Visual Field Loss Frontal Lobe Saccades and Attention Temporal Lobe Combines sensory informationassociated with the recognitionand identification of objects suchas people, places, and things. Parietal Lobe Locating objects Eye movements Drawing/construction of objects Neglect Movement through space2

DefinitionsVisual Perception is the ability to interpret, understand, and define incoming visual information.Form Constancy is the ability to identify objects despite their variation of size, color, shape, position, or texture.Figure ground Perception is the ability to distinguish foreground from background.Visual Closure is the ability to accurately identify objects that are partially covered or missing.Spatial Orientation is the ability to recognize personal position in relation to opposing positions, directions, movement of objects, andenvironmental locations.Unilateral Inattention is phenomenon that causes one to experience an inability to orient and respond to contralateral visual information.Depth Perception is the ability to perceive relative distance in environmental objects.Visual Memory is the ability to take in a visual stimulus, retain its details, and store for later retrieval.Visual Motor Integration is accurate and quick communication between the eyes and hands.Visuocognition is the ability to use visual information to solve problems, make decisions, and complete planning and organizational tasksthrough mental manipulation.Executive Functioning is the ability to reason, plan, problem solve, make inferences, and/or evaluate results of actions and decisions.Memory is taking in new information, holding on to information, and recalling information when needed.Information Processing is taking environmental stimulation in through the five senses, interpreting it, and responding to it.Attention/Concentration is staying awake, alert and ready, focusing, and keeping a train of thought.FocusedAlternatingDivided3

Objectives1. Improve understanding of evaluationprocess for visual perception andcognition for adolescents and adults2. Improve understanding of treatmenttechniques for visual perception andcognition for adolescents and adults,including bottom-up and top-downapproaches, use of technology, and shoebox treatment ideas3. Identify impact of visual perceptual andcognitive barriers on everyday function4

Objective One Improve understanding of evaluationprocess for visual perception and cognitionfor adolescents and adultsWithout knowledge of where a deficit is located in thevisual hierarchy, it is difficulty to design appropriateevaluation and treatment strategies (Warren, 1993).5

Visual Hierarchy(Warren, 1992, 1993) Impact of vision at each skill level of this hierarchy influences the overallintegration of the visual environment. The foundation includes ocularmotor control, visual fields, and visual acuity.These are the basic visual skills required to take in information accurately fromour visual world. Unilateral inattention is represented in this second level, and this deficit wouldcomplicate our ability to properly scan and attend to incoming visualinformation. Decreased visual scanning would present difficulties in pattern recognition,which includes (1) from constancy, (2) figure ground perception, (3) visualclosure, (4) visual organization, and (5) spatial orientation. Moreover, theoptimal functioning of pattern recognition skills are necessary for our ability toretain visual information, also known as visual memory. The highest skill level of this hierarchy is visuocognition, in which we are able tointegrate visual perceptual information with other sensory input in order tocomplete executive functioning tasks, such as planning, problem solving, anddecision making. Determining the cause of a deficit requires an understanding of how braininjury affects the integration of vision at each skill level and how the skill levelsinteract to produce visual perception.6

Vision Screen Visual acuity – How clear it is. Screened using SnellenCharts for distance and near. Accommodation – The automatic adjustment of the eyefor seeing at different distances. Screened using nearacuity chart (or other reading material) and moving inuntil blurry. Diplopia – Another name for double vision. Note if this isin one area/quadrant only, or all the time. Ocular pursuit – The ocular motor skill of following amoving target with the eyes. Observe the clientfollowing a moving object such as a pencil eraser withtheir head still. Note lack of smooth movement, sluggishmovement, overshooting or undershooting the target,and complaints of double vision or pain. Saccadic eye movement –quick, simultaneousmovements of both eyes in the same direction. Askclient to alternate gaze between one object and anotherrapidly. Observe for undershooting, overshooting, orsearching for the target. Convergence – Coordinated movement of the two eyesso that the image of a single point is formed oncorresponding retinal areas. Have the client follow anobject (finger, pen, etc.) in toward their nose. Notedistance from face when they cannot keep image single.Note if one eye breaks before the other. Approximately4 inches is normal, however many can converge to thenose (TTN). Visual scanning – Coordinating eye movement in anorganized fashion (efficient search pattern) whileactively searching the environment for information (i.e.scanning a store shelf for a specific product, reading). Depth perception – The ability to determine the relativedistance between objects, figures, or landmarks and theobserver (i.e. the car in front of you or beside you whendriving or parking a vehicle). Screened using the StereoFly Test or similar. Suppression – The neurological phenomenon of thebrain’s ability to disregard information from one eye;suppression frequently results following prolongeddouble vision, and is thought a natural adaptation of thebrain to try and make sense of the information receivedfrom the eyes. Tested through red/green activities suchas the Worth 4 Dot Test.7

Visual Perceptual and Cognitive ScreeningDeficit AreaClinical ObservationsQuick Clinical ScreeningForm Constancy Difficulty following directions with picturessuch as a recipe, building furniture, orlearning a new board game.Problems recognizing unfamiliar handwritingor new fonts.Difficulty recognizing people wearing differentclothing.Difficulty in mastering the alphabet andnumbers Unable to sort and match socks while foldinglaundryDifficulty locating clothing in drawers duringADLsMissing road signs or vehicles when drivingUnable to locate toys in a toy box Figure Ground Perception Occupational Therapy Adult PerceptualScreening Test (OT-APST)Functional Exercise: Locating various brands and sizes ofitems on a grocery store shelf Locating utensils and correct size bowlsfor baking tasks Reading directions to a game whenwords are in different fonts and colorsBells TestOccupational Therapy Adult PerceptualScreening Test (OT-APST)Star Cancellation TestFunctional Exercise: Locating correct change during amoney management activity Locating puzzle pieces during a jigsawpuzzle activity Locating classroom objects in a pencilbox (ie. Glue stick, eraser, blue crayon,paper clip, etc)8

Visual Perceptual and Cognitive ScreeningDeficit AreaClinical ObservationsQuick Clinical ScreeningVisual Closure Cannot identify traffic signs that are partiallyhidden behind a tree or other vehicleDifficulty locating items in the refrigeratorthat are partially covered Functional Exercise: Completing partiallydrawn pictures orstencils Identifying 10common objects in anoverlapping array of30 itemsLetter and number reversalsDifficulty with spacing and organization ofwritten school work Occupational Therapy AdultPerceptual Screening Test(OT-APST)Baking Tray Test SpatialOrientation UnilateralInattention Applying makeup or shaving only half of thefaceWalking into furniture, doorways, and otherobjectsEating food from half of the tray Occupational Therapy AdultPerceptual Screening Test(OT-APST)Clock Drawing TestLine Bisection TestBells TestStar Cancellation TestAlbert’s TestComb and Razor TestBaking Tray Task9

Visual Perceptual and Cognitive ScreeningDeficit AreaClinical ObservationsQuick Clinical ScreeningDepth Perception Misjudging distances while pouring liquidsFender bender auto accidents, running stop signsDifficulty with grooming, putting in contacts, placement of makeupDifficulty with catching a ballTitmus Fly StereotestRandot StereotestCover/Uncover TestFunctional Exercise: Navigating a therapy gym, hallway,or playground with obstacles Estimating common distances (ie:from person to a fixed distancepoint, such as a car) Pouring liquids into measuringcups Cannot remember sight wordsOften transposes common wordsGets lost in familiar routes, or newly learned routesDifficulty remembering faces or new people Clock Drawing TestScenery Picture Memory Test (SPMT)Spot the Difference for Cognitive Decline(SDCD)Functional Exercise: Study a photograph for 30seconds, and describe the photoand items included Display an array of items or words,remove visual and report as manyitems as they can rememberVisual Memory 10

Visual Perceptual and Cognitive ScreeningDeficit AreaClinical ObservationsQuick Clinical ScreeningVisual Motor Integration Difficulty with letter formationand handwritingDecreased participation in sportsDecreased ability to complete apuzzle or construction of anobject with pictorial instructions Difficulty sorting and organizingpersonal belongingsDifficulty sequencing andplanning for an activity or gameDifficulty making sense of typedor written words, and sequencinga story Visuocognition (Planningand Organizing) Occupational Therapy AdultPerceptual Screening Test(OT-APST)Clock Drawing TestTrail Making A and BFunctional Exercise: Write name or copy asentence on paper Copy simple linedrawings Scissor along variousdotted linesTrail Making A and BFunctional Exercise: Sequence a recipebased on pictorialsteps Sequence a groomingtask with displayeditems (ie: toothpaste,toothbrush, faucet,towel, cup).11

Visual Perceptual and Cognitive ScreeningDeficit AreaClinical ObservationsQuick Clinical ScreeningExecutive Functioning Hard to narrow down the key point or main idea of something. Hard tochoose the best possible solution to a problem.Hard to come up with more than one way of thinking aboutsomething. Hard to see another point of view.Problems evaluating how your plan is going, fixing mistakes, andchanging the plan as needed.Making Poor Decisions Hard to hold on to even brief instructions or explanations. Difficultyremembering what was said at the beginning of a conversation.Difficulty Storing New InformationHard to recall the main point of a conversation, even if it just occurred.May forget important things learned from experience, causingmistakes to be repeated. Memory Logic PuzzlesPacking a medication boxProblem solving picture cardsThe Occupational Therapist's Cognitive ADLWorkbook Decision making scenariosMeal PlanningScavenger Hunt in communityRemembering 3/3 items immediately andafter 5 minutesAsking about current medications andprecautionsAsking to recall previous meal12

Visual Perceptual and Cognitive ScreeningDeficit AreaClinical ObservationsQuick Clinical ScreeningInformation Processing Thinking Speed and ResponseTimes are Slower. It takes longerto understand sensoryinformation and make sense ofwhat is going on in a situation.There may be a long pausebefore the person responds withwords or behavior.Processes only Fragments ofInformation. Parts of informationheard or seen may be missed. Trailmaking AComplete a followingdirections taskTimed cancellation taskGame of speedHard to Stay AlertHard to Focus Attention. Easilydistracted by noises and thingsaround you. Distracted bypersonal thoughts, feelings, andworries.Lose "Train of Thought:“Difficulty alternating attentionbetween tasks and losing theirplaceDifficulty with attending to morethan one thing at a time Trailmaking A and BBasic meal prep activityGrocery shopping exerciseCancellation taskReading medication labels Attention 13

Common Standardized Assessments Baking Tray Test Clock Drawing Test Comb and Razor Test Line Bisection Test Trail Making A and B Bell’s Test Motor Free Visual Perception Test (MVPT-3) Subtests for Visual Discrimination, Visual Figure Ground, Visual Memory, Visual Closure, and Visual Spatial. Test of Visual Perceptual Skills (TVPS-4) Subtests for Visual Discrimination, Visual Memory, Visual-Spatial Relationships, Visual Form-Constancy, Visual Sequential-Memory, Visual Closure, andVisual Figure-Ground Developmental Test of Visual Perception Adolescent and Adult (DTVP-A) (DTVP-2) Visual Motor Search, Visual Motor Speed, Copying, Figure Ground Perception, Visual Closure, and Form Constancy. The Occupational Therapy Adult Perceptual Screening Test (OT-APST) Screens for agnosia, unilateral neglect, body scheme, constructional skills, acalculia, and apraxia scales. Rivermead Perceptual Assessment Battery (RPAB) 16 Performance tests in areas of form constancy, color constancy, sequencing, object completion, figure-ground perception, body image, inattention,spatial awareness Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) 26 subtests in six areas including orientation, visual perception, spatial perception, praxis, visuomotor organization, and thinking operations.14

Common Standardized Assessments Test of Memory and Learning (TOMAL-2) Abstract Visual, Sequential, Linguistic, Numeric, Memory for Location, Object Recall, Facial Memory, etc Weekly Calendar Planning Activity (WCPA) Behavioral Assessment of Dysexecutive Syndrome (BADS) Rule Shift Card Test, Key Search, Temporal Judgement, Zoo map, Modified 6 Element, Action Program Test of Everyday Attention (TEA) Map Search, Elevator Counting, Visual Elevator, Telephone Search, Lottery Executive Function Performance Test (EFPT) Oatmeal preparation, Telephone, Taking Medication, Paying Bills Symbol Digit Modalities Test (SDMT) Verbal and Visual feedback15

DTVP-A Copying Pre and Post Test16

Objective Two Improve understanding of treatment techniques for visualperception and cognition for adolescents and adults,including bottom-up and top-down approaches, use oftechnology, and shoe-box treatment ideas17

Remediation Approach The remedial or developmental approach is typically initiated based on thepremise that the brain can acquire or reacquire function throughenvironmental stimulation. Reacquisition of skills should follow the original path of development. In Piaget’s model of cognitive development, the lower level performancecomponents are acquired prior to more advanced cognitive skills.Treatment activities should place initial emphasis on foundational skills, regardlessof the individual’s level of functioning, in order to ensure that the foundation issolid prior to advancing to higher level cognitive skills. Choosing activities that have multiple levels of difficulty, the ability to alterspeed requirements, and offer the opportunity to adjust levels of attentioncomplexity are important to consider for grading activities up or down tofoster meeting the client’s goals while considering his or her just rightchallenge.18

Cognitive Loading Examples Active listening for recall of informationo Musico Podcastso News storieso How-to videos on YoutubeSimplistic question and answer or categorical namingo Trivia Cards or Applicationso Fitz Ito Joe Name Ito Respond CardsAlternating between multiple taskso Following a sequential keyo Self-timing transitions or following alarmso Self-structure or Structure the therapy hour activity19

ActivityCard GamesExamplesBoard GamesQwirkleTMQ-BitzTMIQ TwistTMI TraxTMAcuityAztackTMGravity MazeTMNMBR9Avalanche Fruit StandWonkyTMConnect 4 Guess Who KerplunkTMSequence/ Sequence Jr Eye Found It CribbagePandemicTMTicket to RideMattel BLINKSet/ Set JrNertz/Peanuts/Dutch BlitzSpot It!Carl’s CardsFast Flip!UnoMattel Skip-BoSwishTMOn the Line/ On the DotTMFluxxDeficit AreaForm ConstancyFigure Ground PerceptionVisual ClosureVisual OrganizationSpatial OrientationUnilateral Inattention/ NeglectDepth PerceptionExecutive FunctioningInformation Processing SpeedMemoryAttentionForm ConstancyFigure Ground PerceptionVisual ClosureVisual OrganizationSpatial OrientationUnilateral Inattention/ NeglectDepth PerceptionExecutive FunctioningInformation Processing SpeedMemoryAttention20

ActivityExamplesDeficit AreasYard GamesLadder BallBean Bag TossWashersCan Jam Horse ShoesYard DartsPutt Putt GolfArcheryCatchTable TennisHopscotchForm ConstancyFigure Ground PerceptionVisual ClosureVisual OrganizationSpatial OrientationUnilateral Inattention/ NeglectDepth PerceptionExecutive FunctioningInformation Processing SpeedMemoryAttentionTabletop/Shoebox ActivitiesPixy CubesTMLabarynthFind It BeadingColor/Paint By Number, MandalaSand ArtTanagramsKnitting/ CrochetingCross StitchWhere’s Waldo / Eye Spy BooksBingoTactile Kinesthetic PegboardSewingWordsearch, crossword puzzlesSudoku, ColorkuForm ConstancyFigure Ground PerceptionVisual ClosureVisual OrganizationSpatial OrientationUnilateral Inattention/ NeglectDepth PerceptionExecutive FunctioningInformation Processing SpeedMemoryAttention21

ActivityExamplesDeficit AreasTablet ExercisesSubway Surfers Cooking Fever Candy Crush Bejewled Temple Run / Minion Rush Look Again! Fruit Ninja Glowburst Minecraft Find It - Match It Vision Tap Tap the Frog iSays Monster Hunt Cut the RopeTMFlow Free Unblock Me Nintendo WiiTM Big Brain Academy – Wii Degree Wii SportsTM Guitar Hero Wii PlayTM Wii FitTM Band Hero X Box Kinect/ 360 Fruit NinjaTM Dance Dance RevolutionTM Deca Sports FreedomTM Kinect Sports Form ConstancyFigure Ground PerceptionVisual ClosureVisual OrganizationSpatial OrientationUnilateral Inattention/ NeglectDepth PerceptionGaming SystemsExecutive FunctioningInformation Processing SpeedMemoryAttentionForm ConstancyFigure Ground PerceptionVisual ClosureVisual OrganizationSpatial OrientationUnilateral Inattention/ NeglectDepth PerceptionExecutive FunctioningInformation Processing SpeedMemoryAttention22

ActivityExamplesDeficit AreasFunctional TherapyActivitiesStructure the Therapy HourGeocachingScavenger HuntsMeal Planning and PreparationMedication packing/pictographsActive PassengerShoppingWork simulationUsing public transportationsystemsApplying make-up, putting incontactsShavingLaundry sorting/foldingHome management activitiesForm ConstancyFigure GroundPerceptionVisual ClosureVisual OrganizationSpatial OrientationUnilateral Inattention/NeglectDepth PerceptionExecutive FunctioningInformation ProcessingSpeedMemoryAttention23

Handwriting before and after24

Compensatory Approach Compensation is a treatment approach that aims tomaximize existing visual function by providing strategiesto enhance the patient's ability to assimilate visualinformation efficiently. A compensatory approach should also place emphasison understanding underlying difficulties in visualperception in order to learn when to initiate the use ofstrategies to overcome limitations. Rather than focusing on one task specific skill, the clientshould gain the ability to use the learned strategies invarious situations. Warren supports the use of practicing strategies forvisual perceptual deficits within context to ensurecarryover of application to ADLs.25

Compensatory Approach Pattern Recognition UnilateralInattention Reducing overlapp

Definitions Visual Perception is the ability to interpret, understand, and define incoming visual information. Form Constancy is the

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