Telerehabilitation for people with low vision

Feasibility of telerehabilitation to address the orientation and mobility needs of individuals with visual impairment: perspectives of current guide dog users

OBJECTIVE

To assess guide dog users' perspectives on the feasibility of telerehabilitation for their O&M needs.

METHOD

An online survey gathered insights from 56 guide dog (GD) users (Mean age = 59, Mean GD used = 4, Mean duration of use = 22 years). Thirteen GD users further participated in interviews or focus groups to explore survey responses. Data were analyzed using content analysis.

FINDINGS

Most (40) were blind, and 16 had low vision, with intermediate (25) and advanced (25) communication technology proficiency. Most GD users (46) underwent residential training, and 10 received one-on-one visits. Qualitative analysis revealed acceptance of telerehabilitation services, citing accessibility as an advantage. However, GD users expressed concerns about safety, potential loss of behavioral observation, and social contact loss. Success depended on the type of technology, service type, and personal attributes.

CONCLUSION

While feasible, telerehabilitation services may not be universally suitable for all training stages. Flexibility and applicability in service design are necessary to accommodate individual preferences and experience levels.

Barriers and enablers to low vision care and rehabilitation in sub-Saharan Africa within a global context

Low vision is an uncorrectable form of visual impairment that affect millions of people worldwide. Low vision care and rehabilitation are essential to improving the independence of affected individuals. Even though sub-Saharan Africa has one of the highest burdens of low vision globally, there are inadequate care and rehabilitation services in most countries and in some cases they are non-existent This scoping review aimed to identify the barriers and enablers to low vision care and rehabilitation in sub-Saharan Africa and assess these within the global context. The review was conducted using the five-step Arksey and O'Malley framework. Search terms were formulated based on the research questions and a search strategy was designed to search for eligible research articles from electronic databases; Pubmed, Ovid, Medline, and Embase. The data was screened by two members of the research team in accordance with set inclusion and exclusion criteria. Twenty-five out of 260 articles satisfied the inclusion criteria for the study. Inadequate low vision care infrastructure and supplies, non-standardised training of low vision care providers, health system failure and poor awareness of low vision care were the main barriers noted by eye care practitioners. Patients living with low vision cited the cost and availability of low vision aids, societal stigma, and poor awareness of services as the main barriers. No direct enablers were identified in sub-Saharan Africa; however, practitioners suggested improved training in low vision as a potential enabler. The barriers to low vision care and rehabilitation services identified were not unique to sub-Saharan Africa when viewed within a global context. Adopting and adapting solutions from other countries may therefore assist in improving low vision care and rehabilitation in sub-Saharan Africa.

Usability and feasibility of E-nergEYEze: a blended vision-specific E-health based cognitive behavioral therapy and self-management intervention to reduce fatigue in adults with visual impairment

BACKGROUND

Over 50% of adults with visual impairment experience severe fatigue. Therefore, we developed a guided E-health intervention based on cognitive behavioral therapy and self-management to reduce fatigue in this population. This pilot study evaluated the usability, feasibility, fidelity and potential effectiveness of E-nergEYEze.

METHODS

E-nergEYEze was developed by a design team and customized by conducting a pilot study using an iterative development strategy. The intervention was first tested in a usability study among adults with visual impairment (n = 5). Participants were asked to think-aloud while exploring the intervention features and a semi-structured interview was performed afterwards. Subsequently, the enhanced intervention was tested in a feasibility study. Adults with visual impairment and severe fatigue (n = 10) followed the intervention partially with guidance from a social worker and one-time computer trainer support. Fatigue severity (Checklist Individual Strength), fatigue impact (Modified Fatigue Impact Scale) and cognitive behavioral therapy skills (Competencies of Cognitive Therapy Scale-Self Report) were measured at baseline and at three months follow-up and analyzed with the Wilcoxon signed-rank test. The intervention was evaluated through evaluation forms.

RESULTS

The usability study resulted in adjustments to content and lay-out with regard to optically shortened text sentences, separate pages for information and assignments with one read-aloud audio and an additional descriptive explanation of page content. Digital challenges were overcome with mandatory computer training and e-platform modifications. The feasibility study showed a positive trend in reducing fatigue severity (Z -6.108; P < .001; SD 8.4), impact of fatigue (Z - 4.451; P < .001; SD 11.4) and cognitive behavioral therapy skills (Z -2.278; P = .023; SD 19.3). Participants gave useful feedback regarding accessibility, content and guidance, with an overall positive experience. The intervention was rated with a median score of 8 (range 7-10).

CONCLUSION

We developed, evaluated and optimized E-nergEYEze by applying a user-centered and iterative approach. E-nergEYEze showed a promising trend to reduce fatigue severity and impact of fatigue and to increase cognitive behavioral therapy skills. The study methods were feasible and the fidelity of the intervention protocol was suitable. Performing a randomized controlled trial is warranted to give insight into whether E-nergEYEze is cost-effective in reducing severe fatigue in adults with visual impairment.

TRIAL REGISTRATION

International Clinical Trial Registry Platform: NL7764. Date registered: 28-05-2019.

Telerehabilitation for people with low vision

BACKGROUND

Low vision affects over 300 million people worldwide and can compromise both activities of daily living and quality of life. Rehabilitative training and vision assistive equipment (VAE) may help, but some visually impaired people have limited resources to attend in-person visits to rehabilitation clinics to be trained to learn to use VAE. These people may be able to overcome barriers to care through access to remote, internet-based consultation (telerehabilitation).

OBJECTIVES

To compare the effects of telerehabilitation with face-to-face (e.g. in-office or inpatient) vision rehabilitation services for improving vision-related quality of life and near reading ability in people with visual function loss due to any ocular condition. Secondary objectives were to evaluate compliance with scheduled rehabilitation sessions, abandonment rates for VAE devices, and patient satisfaction ratings.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which contains the Cochrane Eyes and Vision Trials Register) (2021, Issue 9); Ovid MEDLINE; Embase.com; PubMed; ClinicalTrials.gov; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any language restriction or study design filter in the electronic searches; however, we restricted the searches from 1980 onwards because the internet was not introduced to the public until 1982. We last searched CENTRAL, MEDLINE Ovid, Embase, and PubMed on 14 September 2021, and the trial registries on 16 March 2022.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) or controlled clinical trials (CCTs) in which participants diagnosed with low vision had received vision rehabilitation services remotely from a human provider using internet, web-based technology compared with an approach involving in-person consultations.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts retrieved by the searches of the electronic databases and then full-text articles for eligible studies. Two review authors independently abstracted data from the included studies. Any discrepancies were resolved by discussion.

MAIN RESULTS

We identified one RCT/CCT that indirectly met our inclusion criteria, and two ongoing trials that met our inclusion criteria. The included trial had an overall high risk of bias. We did not conduct a quantitative analysis since multiple controlled trials were not identified.  The single included trial of 57 participants utilized a parallel-group design. It compared 30 hours of either personalized low vision training through telerehabilitation with a low vision therapist (the experimental group) with the self-training standard provided by eSight using the eSkills User Guide that was self-administered by the participants at home for one hour per day for 30 days (the comparison group). The trial investigators found a similar direction of effects for both groups for vision-related quality of life and satisfaction at two weeks, three months, and six months. A greater proportion of participants in the comparison group had abandoned or discontinued use of the eSight Eyewear at two weeks than those in the telerehabilitation group, but discontinuance rates were similar between groups at one month and three months. We rated the certainty of the evidence for all outcomes as very low due to high risk of bias in randomization processes and missing outcome data and imprecision.   AUTHORS' CONCLUSIONS: The included trial found similar efficacy between telerehabilitation with a therapist and an active control intervention of self-guided training in mostly younger to middle-aged adults with low vision who received a new wearable electronic aid. Given the disease burden and the growing interest in telemedicine, the two ongoing studies, when completed, may provide further evidence of the potential for telerehabilitation as a platform for providing services to people with low vision.

Do patients with and survivors of COVID-19 benefit from telerehabilitation? A meta-analysis of randomized controlled trials

Background

Coronavirus disease 2019 (COVID-19) significantly impacts physical, psychological, and social functioning and reduces quality of life, which may persist for at least 6 months. Given the fact that COVID-19 is a highly infectious disease and therefore healthcare facilities may be sources of contagion, new methods avoiding face-to-face contact between healthcare workers and patients are urgently needed. Telerehabilitation is the provision of rehabilitation services to patients at a distance via information and communication technologies. However, high-quality evidence of the efficacy of telerehabilitation for COVID-19 is still lacking. This meta-analysis aimed to investigate the efficacy of telerehabilitation for patients with and survivors of COVID-19.

Methods

We searched the Cochrane Library, EMBASE, Medline (via PubMed), PEDro, ClinicalTrials.gov, and WHO International Clinical Trials Registry Platform from January 1st, 2020 to April 30th, 2022 for randomized controlled trials published in English, which aimed to evaluate the efficacy of telerehabilitation vs. face-to-face rehabilitation, usual care, or no treatment for COVID-19. Methodological quality and overall evidence quality of the included studies were assessed. The statistical reliability of the data was quantified using the trial sequential analysis.

Results

Seven randomized controlled trials with eight comparisons were included and all of them were used for meta-analysis. The meta-analyses of absolute values showed the superiority of telerehabilitation over no treatment or usual care for dyspnea (Borg scale: mean difference = -1.88, -2.37 to -1.39; Multidimensional dyspnea-12: mean difference = -3.70, -5.93 to -1.48), limb muscle strength (mean difference = 3.29; 2.12 to 4.47), ambulation capacity (standardized mean difference = 0.88; 0.62 to 1.14), and depression (mean difference = -5.68; -8.62 to -2.74). Significant improvement in these variables persisted in the meta-analyses of change scores. No significant difference was found in anxiety and quality of life. No severe adverse events were reported in any of the included studies.

Conclusions

Moderate- to very low-quality evidence demonstrates that telerehabilitation may be an effective and safe solution for patients with and survivors of COVID-19 in dyspnea, lower limb muscle strength, ambulation capacity, and depression. Further well-designed studies are required to evaluate the long-term effects, cost-effectiveness, and satisfaction in larger samples.

Providers' Shift to Telerehabilitation at the U.S. Veterans Health Administration During COVID-19: Practical Applications

Telerehabilitation provides Veteran patients with necessary rehabilitation treatment. It enhances care continuity and reduces travel time for Veterans who face long distances to receive care at a Veterans Health Administration (VHA) medical facility. The onset of the COVID-19 pandemic necessitated a sudden shift to telehealth–including telerehabilitation, where a paucity of data-driven guidelines exist that are specific to the practicalities entailed in telerehabilitation implementation. This paper explicates gains in practical knowledge for implementing telerehabilitation that were accelerated during the rapid shift of VHA healthcare from out-patient rehabilitation services to telerehabilitation during the COVID-19 pandemic. Group and individual interviews with 12 VHA rehabilitation providers were conducted to examine, in-depth, the providers' implementation of telerehabilitation. Thematic analysis yielded nine themes: (i) Willingness to Give Telerehabilitation a Chance: A Key Ingredient; (ii) Creativity and Adaptability: Critical Attributes for Telerehabilitation Providers; (iii) Adapting Assessments; (iv) Adapting Interventions; (v) Role and Workflow Adaptations; (vi) Appraising for Self the Feasibility of the Telerehabilitation Modality; (vii) Availability of Informal, In-Person Support Improves Feasibility of Telerehabilitation; (viii) Shifts in the Expectations by the Patients and by the Provider; and (ix) Benefit and Anticipated Future of Telerehabilitation. This paper contributes an in-depth understanding of clinical reasoning considerations, supportive strategies, and practical approaches for engaging Veterans in telerehabilitation.

Teleophthalmology Service: Organization, Management, Actual Current Applications, and Future Prospects

Teleophthalmology (TO) consists of the clinical and therapeutic approach to the patient (e-Health) using informatic and telecommunication systems. Already widespread worldwide, it aims to improve patient care, expand the healthcare offer, and access to medical care by reducing overall costs. Despite the organizational, legal, and management difficulties, the substantial economic investments necessary for the start-up of equipped structures and efficient territorial services are amply rewarded by economic results and optimal services for professionals and patients. This review specifically analyses the current scenario of teleophthalmology, the points for and against its application in different sociodemographic realities, and in particular, the current and future fields of use.

Head-mounted Visual Assistive Technology-related Quality of Life Changes after Telerehabilitation

SIGNIFICANCE

Head-mounted low vision devices have become a viable alternative to enhance residual vision. This study supports the use of a head-mounted display to improve aspects of functional vision and quality of life. Much is still unknown regarding the required frequency, duration, or potential effectiveness of this telerehabilitation training protocol or what characteristics best identify optimal users.

PURPOSE

A randomized study explored the effect of telerehabilitation on quality of life and functional vision in individuals with low vision using a head-mounted display.

METHODS

We recruited 57 participants (age, 21 to 82 years; mean, 54.5 years) among new prospective eSight Eyewear users, randomized 1:1 into two parallel groups; the experimental group received the telerehabilitation training provided by a low vision therapist, whereas the control group received the self-training standard offered by the device manufacturer and without involvement of a low vision therapist. The primary outcome measures were the impact of telerehabilitation on validated measures of assistive technology-related quality of life: the Psychosocial Impact of Assistive Devices Scale and the Quebec User Evaluation of Satisfaction with Assistive Technology scale. Exploratory outcomes were the assessment of self-reported functional vision using the Veterans Affairs Low Vision Visual Functioning Questionnaire-48 and cybersickness associated with head-mounted display use with the Simulator Sickness Questionnaire.

RESULTS

Assistive technology-related quality of life was improved when measured by the satisfaction scale but not the psychosocial scale within the first 3 months, independently of training type. Overall, functional vision improvement was observed within the first 2 weeks of device use and maintained during the 6-month study, independently of group type. Cybersickness outcomes were similar between training groups and did not change significantly for 6 months.

CONCLUSIONS

eSight Eyewear, either with telerehabilitation or with the manufacturer self-training comparison, improved functional vision and increased users' quality of life within the initial 3 months of device training and practice.

Personalized Telerehabilitation for a Head-mounted Low Vision Aid: A Randomized Feasibility Study

SIGNIFICANCE

A recent trend in low vision rehabilitation has been the use of portable head-mounted displays to enhance residual vision. Our study confirms the feasibility of telerehabilitation and informs the development of evidence-based recommendations to improve telerehabilitation interventions to reduce device abandonment.

PURPOSE

To develop evidence-based recommendations for telerehabilitation, we conducted a feasibility study in preparation for a future randomized trial on the use of head-mounted displays.

METHODS

We recruited novice eSight Eyewear users, randomized 1:1: the experimental group received telerehabilitation by a low vision therapist using video conferencing; the control group completed at home self-training provided by the device manufacturer. The primary feasibility outcomes were whether the recruitment goal of 60 participants (30/group) was attainable within 1 year and how participants judged the accessibility and acceptability of the telerehabilitation. An exploratory outcome was the impact of telerehabilitation on eSight Eyewear use behavior.

RESULTS

Among 333 eSight users, 57 participants were enrolled, of which 35% withdrew from the study, whereas the remainder completed the 6-month follow-up. The withdrawal rate was higher in the control group but did not differ significantly from the experimental group. High accessibility (93% of participants accessed the platform) and global acceptability (100% overall satisfaction) were reported among those who completed the telerehabilitation protocol. The therapist had no difficulty judging the participants' reading performances qualitatively while participants used their device to read their eSkills and VisExc guides. Most participants improved their daily activities, based on qualitative reports of the attained goals. Seventy-nine percent of individuals declined to participate, whereas 16% of participants decided not to use eSight Eyewear anymore.

CONCLUSIONS

The data demonstrated the feasibility of a randomized controlled telerehabilitation study for people with low vision using a head-mounted display. Positive feedback from the participants and the therapist suggests the potential value of this modality for low vision services.

Tele-rehabilitation for visually challenged students during COVID-19 pandemic: Lesson learned

PURPOSE

The COVID-19 outbreak poses a global crisis in health care delivery system, including habilitation and rehabilitation services. In this study, we shared our experiences on telerehabilitation services established primarily for students with visual disabilities (SwVD) amidst COVID-19 pandemic and its outputs.

METHODS

Following the lockdown declared on March 23, 2020, the rehabilitative team of a tertiary eye center in north India received information that many visually challenged students (VCS) were stranded in schools for the blind in Delhi, and feeling with anxiety and panic in absence of teachers. Shortly, the room for vision rehabilitation clinic was set-up for telefacilities. The intended services were explained while disseminating the mobile numbers. A semi-structured questionnaire consisting of closed and open-ended was developed to record COVID-19 knowledge and concerns. Inductive content analysis was used to report the qualitative information.

RESULTS

As of June 30, 2020, a total of 492 clients contacted the team, with maximum from Delhi (41.5%), and predominantly males (78.8%). Around 80.3% of callers were VCS with age range of 11 to 30 years. The two most frequently encountered health needs were itching in eyes (36.1%) and headache (29%). Television news was the most used medium among callers to get COVID-19 information. Cough is a less frequently known mode of transmission (28%), similarly handwashing as a less known for prevention (17.2%). Eight concerns were recorded based on qualitative data analysis.

CONCLUSION

Telerehabilitation provides valuable insights and has the potential to address various concerns, uncertainty, anxiety, and fear among VCS during the pandemic.

Lockdown low vision assessment: an audit of 500 telephone-based modified low vision consultations

Purpose

Non‐urgent face‐to‐face outpatient ophthalmology appointments were suspended in the United Kingdom in March 2020, due to the COVID‐19 outbreak. In common with other centres, Moorfields Eye Hospital NHS Foundation Trust (London) offered modified telephone consultations to new and follow‐up patients in the low vision clinic. Here we assess the success of this telephone service.

Methods

Data were collected for 500 consecutive telephone low vision appointments. Successful completion of the assessment and clinical outcomes (low vision aids prescribed, onward referral) were recorded.

Results

Telephone assessments were completed for 364 people (72.8%). The most common reasons for non‐completion were either no answer to the telephone call (75 people, 15%), or the patient declining assessment (20 people, 4%). There was no association between age and the likelihood of an assessment being completed. 131 new low vision aids were dispensed, 77 internal referrals were made and 15 people were referred to outside services. More than 80% of the low vision aids prescribed were useful.

Conclusions

Telephone low vision assessments were completed in about three‐quarters of cases. About one‐quarter of consultations resulted in new low vision aids being dispensed, which were generally found useful. Telephone low vision assessments can be used successfully in a large low vision clinic, but have many limitations when compared to face‐to‐face assessments.

Validation of a portable, remotely delivered refraction approach compared to standard in-clinic refraction in a low-vision population

INTRODUCTION

A low-vision assessment (LVA) is critical in developing a vision rehabilitation plan. A remotely delivered LVA that replicates a standard in-clinic assessment may bridge the gap for patients not accessing care due to the limited quantity and distribution of low-vision providers. Within an LVA, an accurate and consistent assessment of refraction error is an essential component. No system has currently been validated for the purposes of a remote LVA. The purpose of this study was to validate a commercially available portable refraction approach in a low-vision population.

METHODS

Low-vision patients (n = 26) or normally sighted patients (n = 25) underwent a refraction assessment using the Adaptica® 2WIN autorefractor, adaptor scope (Kaleidos) and VisionFit phoropter portable refraction devices, as well as a standard autorefractor (Huvitz) and phoropter (Haag-Streit). Refraction data between systems and populations were compared using intraclass correlations. Bland-Altman plots were used to assess the differences between devices.

RESULTS

Spherical equivalent values were found to be reproducible between standard and experimental autorefraction devices (intraclass correlation coefficient (ICC) > 0.8) in both low-vision and normally sighted groups. Similarly, manifest refraction was highly consistent (ICC > 0.8) between devices in all groups. The Bland-Altman plots showed clinically acceptable mean differences of 0.701 between autorefraction methods and -0.116 between manifest refraction methods.

DISCUSSION

The 2WIN/VisionFit system can reliably generate refraction values across a spectrum of errors in normally sighted and visually impaired people, and would be feasible to deliver remotely.

Telemedicine in ophthalmology in view of the emerging COVID-19 outbreak

Purpose

Technological advances in recent years have resulted in the development and implementation of various modalities and techniques enabling medical professionals to remotely diagnose and treat numerous medical conditions in diverse medical fields, including ophthalmology. Patients who require prolonged isolation until recovery, such as those who suffer from COVID-19, present multiple therapeutic dilemmas to their caregivers. Therefore, utilizing remote care in the daily workflow would be a valuable tool for the diagnosis and treatment of acute and chronic ocular conditions in this challenging clinical setting. Our aim is to review the latest technological and methodical advances in teleophthalmology and highlight their implementation in screening and managing various ocular conditions. We present them as well as potential diagnostic and treatment applications in view of the recent SARS-CoV-2 virus outbreak.

Methods

A computerized search from January 2017 up to March 2020 of the online electronic database PubMed was performed, using the following search strings: “telemedicine,” “telehealth,” and “ophthalmology.” More generalized complementary contemporary research data regarding the COVID-19 pandemic was also obtained from the PubMed database.

Results

A total of 312 records, including COVID-19-focused studies, were initially identified. After exclusion of non-relevant, non-English, and duplicate studies, a total of 138 records were found eligible. Ninety records were included in the final qualitative analysis.

Conclusion

Teleophthalmology is an effective screening and management tool for a range of adult and pediatric acute and chronic ocular conditions. It is mostly utilized in screening of retinal conditions such as retinopathy of prematurity, diabetic retinopathy, and age-related macular degeneration; in diagnosing anterior segment condition; and in managing glaucoma. With improvements in image processing, and better integration of the patient’s medical record, teleophthalmology should become a more accepted modality, all the more so in circumstances where social distancing is inflicted upon us.