How to assess visual function in acquired brain injury-Asking is not enough

Assessment of visual problems after acquired brain injury: a survey of current practice in Danish hospitals

OBJECTIVES

To explore current hospital practice in relation to the assessment of vision problems in patients with acquired brain injury.

DESIGN

A survey study.

SUBJECTS

A total of 143 respondents from hospital settings, with background in occupational therapy and physical therapy, participated in the survey.

METHODS

The survey questionnaire, developed collaboratively by Danish and Norwegian research groups, encompassed 22 items categorically covering "Background information", "Clinical experience and current practice", "Vision assessment tools and protocols", and "Assessment barriers". It was sent out online, to 29 different hospital departments and 18 separate units for occupational therapists and physiotherapists treating patients with acquired brain injury.

RESULTS

Most respondents worked in acute or subacute hospital settings. Few departments had an interdisciplinary vision team, and very few therapists had formal education in visual problems after acquired brain injury. Visual assessment practices varied, and there was limited use of standardized tests. Barriers to identifying visual problems included patient-related challenges, knowledge gaps, and resource limitations.

CONCLUSION

The study emphasized the need for enhanced interdisciplinary collaboration, formal education, and standardized assessments to address visual problems after acquired brain injury. Overcoming these challenges may improve identification and management, ultimately contributing to better patient care and outcomes in the future.

Symptoms at stroke onset as described by patients: a qualitative study

BACKGROUND

Stroke is a common and severe disease that requires prompt care. Symptom expressions as one-sided weakness and speech difficulties are common and included in public stroke campaigns. For some patients stroke can present with subtle and less common symptoms, difficult to interpret. The symptom severity assessed by the National Institutes of Health Stroke Scale has decreased, and symptoms at onset may have changed. Therefore, we aimed to investigate how patients describe their symptoms at the onset of a first-time stroke.

METHODS

The study used a qualitative descriptive design and conventional content analysis. Data were collected through recorded interviews with 27 patients aged 18 years and older hospitalised with a first-time stroke between October 2018 and April 2020. Data were analysed on a manifest level.

RESULTS

Symptoms at stroke onset were presented in two themes: Altered Reality and Discomfort and Changed Body Functions and described in five categories. Various types of symptoms were found. All symptoms were perceived as sudden, persistent, and never experienced before and this appear as a "red thread" in the result. Regardless of symptom expressions, no specific symptom was described as more severe than another.

CONCLUSIONS

Stroke symptoms were described with a variety of expressions. Many described complex symptoms not typical of stroke, which can make it difficult to recognise the symptoms as a stroke and delay medical care. Public stroke campaigns should emphasize the importance of seeking medical care at the slightest suspicion of stroke and could be designed to help achieve this.

Individualized goals expressed by patients undergoing stroke rehabilitation: an observational study

OBJECTIVES

To explore the rehabilitation goals measured with the Patient-Specific Functional Scale (PSFS) in patients undergoing acute and subacute stroke rehabilitation. In addition, to assess whether PSFS goals corresponded to impairments and activity limitations, as identified by standardized measures.

DESIGN

Observational study.

PARTICIPANTS

A total of 71 participants undergoing inpatient stroke rehabilitation.

METHODS

The PSFS goals were linked to second-level categories in the International Classification of Functioning, Disability and Health (ICF), using established linking rules. Frequencies of the linked ICF categories were calculated. Frequencies of participants with limitations in walking, activities of daily living (ADL), vision, language, and cognition, were calculated, along with goals in corresponding areas of functioning.

RESULTS

The participants' goals were linked to 50 second-level ICF categories, comprising areas such as walking and moving, ADL, language, vision, and cognition. The most frequent ICF categories were "Moving around in different locations" (n = 24), "Walking" (n = 23), "Toileting" (n = 16), "Hand and arm use (n = 12) and "Fine hand use (n = 12)". Of participants with limitations in walking, cognition, and vision, 85%, 10%, and 16%, respectively, had goals in these areas.

CONCLUSION

Participants' goals included walking, ADL, language, vision, and cognition. Few with impairments in cognition or vision had goals in these corresponding areas on the PSFS.

Oculomotor screening and neuro-visual rehabilitation following pediatric brain tumor resection

Visual difficulties are common after brain tumors, despite a lack of visual complaints at diagnosis. These include difficulties with eye movements, visual coordination, vergence, accommodation, and photophobia, in addition to more obvious problems such as visual field defects. This case report presents the results of a thorough neuro-visual evaluation in a boy with sequelae after a brain tumor including intermittent double vision that was not explained by routine visual examination. Subjective complaints included poor reading perseverance, intermittent blurred and double vision, headache around the eyes when performing near activities, less efficient eye movement behavior in reading tasks, and increased sensitivity to visual motion. The patient participated in a multidisciplinary visual rehabilitation program that included reading glasses with prism compensation and tinted glasses, as well as training with the aim of improving eye teaming, near vision functions, and perseverance in eye movements. The patient responded quickly to the vision therapy program, with positive changes after just four weeks. Repeated neuro-visual evaluations over eight months showed remarkable improvements that were stable over time. This encouraging case report supports the notion that neuro-visual evaluation and rehabilitation should be included in the follow-up of patients after brain tumors.

Visual Problems are Associated with Long-Term Fatigue after Stroke

OBJECTIVE

Post-stroke fatigue may be associated with functioning even in patients with mild stroke. In order to guide rehabilitation, the aim of this study was to investigate the independent contribution of 12 function-related domains to severe long-term fatigue.

DESIGN

Observational follow-up study.

SUBJECTS

A total of 144 stroke survivors (mean age 67.3, standard deviation (SD) 10.9 years) were included.

METHODS

Fatigue 3-4 years post-stroke was measured with the Fatigue Severity Scale (cut-off ≥5). Independent variables were the multidimensional Stroke-Specific Quality of Life scale with 12 domains, demographics, and baseline stroke characteristics.

RESULTS

Most of the participants had mild and moderate stroke. Thirty-five percent (n = 51) reported severe fatigue 3-4 years after stroke. Those living with a significant other, and working participants reported significantly less fatigue. All domains of the Stroke-specific Quality of Life scale were significantly associated with the Fatigue Severity Scale. Adjusted for age, sex, marital status, and work status, the domains "energy", "mood", and, unexpectedly, the domain "vision", were all variables independently associated with severe long-term fatigue.

CONCLUSION

Stroke survivors with prominent self-reported visual problems were more likely to experience fatigue. This finding should be verified in further studies. Visual examination and visual rehabilitation may reduce fatigue in selected stroke survivors.

'If we don't assess the patient's vision, we risk starting at the wrong end': a qualitative evaluation of a stroke service knowledge translation project

BACKGROUND

Visual impairments (VIs) affect 60% of stroke survivors and have negative consequences for rehabilitation and quality of life poststroke. Symptoms of VIs post stroke are difficult to identify for stroke survivors and health care professionals without using a structured vision assessment. In this study, we qualitatively evaluate the implementation outcomes after implementing a structured visual assessment with the Competence, Rehabilitation of Sight after Stroke Vision (KROSS) assessment tool in stroke care services.

METHODS

This is a qualitative study comprising four focus group interviews. The health care personnel (HCP) involved in the implementation or with experience using the KROSS assessment tool in practice were invited to participate. We used Proctor et al.'s definitions of implementation outcomes as a framework, which informed the interview guide and analysis. We used a deductive - inductive content analysis, as described by Elo and Kyngäs.

RESULTS

The participants found the structured vision assessment with the KROSS tool as being acceptable; they expressed a motivation and intention to use the new routine in practice. They believed it was important to assess their patient's visual function because it influenced other rehabilitation activities and activities of daily living. Most of the participants reported having adopted the vision assessment in their practice, except for those participants from the home care services who experienced that they have few stroke survivors to follow up on. The assessment was believed to be more appropriate to perform within the rehabilitation services where there is more of a focus on functional assessments. Although vision assessment was new to all the participants, they felt that they improved their vision assessment skills by regularly using the assessment tool. Together with sufficient instructions and supervision, they believed that vison assessment was feasible for their practise. Including the vison assessment in the existing routines and systems was important to promote sustainable implementation.

CONCLUSION

Implementing a structured vision assessment with the KROSS tool in health care services was experienced as acceptable and feasible. The new routine led to increased attention towards poststroke VIs and increased collaboration with vision experts. Tailoring the routine to each practice and how they organise their work can support the integration of a vision assessment in their routines. To promote better vision care poststroke vision assessment and follow up should be included in the stroke care pathways.

From Provider to Advocate: The Complexities of Traumatic Brain Injury Prompt the Evolution of Provider Engagement

Treating a patient with traumatic brain injury requires an interdisciplinary approach because of the pervasive, profound and protean manifestations of this condition. In this review, key aspects of the medical history and review of systems will be described in order to highlight how the role of any provider must evolve to become a better patient advocate. Although this review is written from the vantage point of a vision care provider, it is hoped that patients, caregivers and providers will recognize the need for a team approach.