Running Head: LVDS IN READING REHAB

Effectiveness of Low Vision Devices in Reading Rehab

Charlene Blackburn
Adriane Heineman

University of Utah
Department of Occupational and Recreational Therapies
LVDS IN READING REHAB

Introduction

The face of America is changing. Never before has the aging population been as large or

as diverse as it is today. This simple fact has broad implications for us as a society. From the

economy - the sheer productivity of our nation, types of jobs available, size of the workforce,

and housing issues; to policy decisions - tax questions, workforce incentives, entitlement

programs - the changing demographics will affect us all. The percentage of Americans over the

age of 65 is growing faster than the total population and is projected to more than double by

2060 to 24 percent from 15 percent of the overall US population (Population Reference Bureau,

2016).

Of the economic, personal, and social costs associated with an aging population, the

most significant involve health care. Vision loss is a severe threat to independence and

occupational participation and performance in adults age 65 and older (National Eye Institute,

2004). Vision loss is an often misunderstood and underappreciated medical and social issue.

Long considered an expected part of the aging process, the significant indirect and direct costs

of low vision to society and families deserve more attention, along with the potential for

eyesight preservation and increased function through rehabilitation. Directly, low vision

removes people from the workforce and often involves significant costs associated with

caregiving and support. Indirectly, the losses are personal and substantial. Increased depression

often accompanies a decrease in independence, mobility, and social participation (Hamade,

Hodge, Rakibuz-Zaman & Malvankar-Mehta, 2016). The caregiver burden directed at families is

often significant both personally and financially (Fok, 2011).

LVDS IN READING REHAB

The psychosocial and physical limitations experienced by a reduction in visual ability can

vary widely by individual. Reading is the most important occupation affected by vision loss, and

is implicated in many important life skills. This impact on a person’s quality of life is substantial.

Social effects include technology and related communication devices and personal computers;

safety effects are medication labels, food labels, and household cleaner labels (Smallfield, Clem

& Myers, 2013). Mobility is affected by inability to read road signs, maps, and community signs.

Reading rehabilitation addresses these instrumental activities of daily living (IADLs) in addition

to finances, money management and reading financial statements.

Low vision is considered a disability and involves visual impairment that cannot be

corrected with medicine, surgery, or conventional eyeglasses (Arbesman, Lieberman &

Berlansetin, 2013). It includes a loss of visual acuity, visual field, and contrast sensitivity. Visual

acuity is a measurement of the sharpness and clarity of vision, usually described in terms of

your ability to clearly see at 20 feet, for example, 20/20 vision. Visual field loss is commonly

experienced as peripheral vision loss. Contrast sensitivity refers to the ability to distinguish

objects against different colors and patterns, or in low-light levels and glare. Night driving is an

activity that requires good contrast sensitivity. In combination, these three measures are critical

to functional tasks such as reading. The four conditions which, together, are the greatest

contributors to low vision in older adults are age related macular degeneration (AMD),

glaucoma, diabetic retinopathy, and cataracts (Arbesman et al., 2013). Of these four conditions,

AMD is the leading cause of low vision in this population (Hamade et al., 2016).

Low vision rehabilitation significantly impacts almost all areas of an individual’s life;

however, further research is required regarding effective and available devices, strategies, and
LVDS IN READING REHAB

services in order to meet the therapy needs of those living with low vision. Although not much

is known about the impact of LVDs on reading rehab and an individual’s overall ability to

participate in daily occupations, there are many available devices that, paired with

environmental adaptations and strategies, have improved reading and occupational

participation in other activities for those with low vision.

The goal of this study is to explore the effectiveness of low vision devices (LVDs) in

reading rehabilitation for elderly adults. Currently, reading rehabilitation consists of a variety of

methods including environmental adaptation strategies such as lighting modifications, contrast,

tactile and auditory strategies, magnification, eccentric viewing training, and a variety of optical

devices and technological equipment (Huefner, Kaldenberg & Berger, 2008). LVDs are often

prescribed to assist with functional reading ability, which is measured by reading speed.

Occupational therapists work to educate and train individuals with low vision in adapting their

environments and tasks in order to increase occupational participation. This also includes LVD

training and use. We focused on researching the effectiveness of LVDs because of the increase

in the number of older adults affected by age-related vision loss and the need to evaluate the

effectiveness of devices used. The wide variety of LVDs available and the significant costs

associated makes discriminating their efficacy especially pertinent.

Methods

The method for this paper involved summarizing and analyzing 11 peer-reviewed

journal articles retrieved from the online databases PubMed and CINAHL with a year range of

2007-2018. Search key terms included: low vision, reading, occupational therapy, and

rehabilitation. Abstracts were analyzed for relevance and full-text articles reviewed for quality.
LVDS IN READING REHAB

Our goal was to collect and evaluate research information on the topic of low vision reading

rehabilitation in older adults. Subsequently, the aim was to discover an evidenced-based,

unbiased conclusion regarding effective tools being used in low vision reading rehabilitation.

Of the eleven articles reviewed; five described Level I research evidence, one described

Level II, two described Level II, one described Level IV, and two described Level V. Quality of

articles was judged based on the level of evidence provided and transferability of population

selection. Inclusion criteria included; addresses low vision assistive devices, recent research

conducted within last ten years, population studied focused on older adults with low vision

impairment. We excluded two articles that examined low vision rehabilitation in children.

Quality was judged individually by members of our group and a final consensus achieved after

comparing comments.

Results

It is common for doctors to prescribe LVDs for a variety of tasks to maximize current

vision and independence. They are categorized as optical and non-optical devices. Optical

devices include magnifiers (stand, handheld, telescopes and electronic), and prescription

glasses with high power lenses. Non-optical devices include adaptations to improve function:

lighting, eccentric viewing training, audio recordings and digital assistants, or tactile strategies.

Several of the studies which we reviewed were found to show significant improvement

in occupational participation and improved reading speed when the use of LVDs was coupled

with occupational therapy.

In research conducted by Stelmack and Tang and Wei and Massof (2012), standard low

vision treatment was tested against low vision treatment in conjunction with occupational
LVDS IN READING REHAB

therapy. The treatment group received five weekly two-hour vision therapy sessions, a home

visit by a therapist to teach strategies for current level of vision and the use of LVDs in the

home, psychological counseling, homework, which was to be done during the week with follow

up between the patient and therapist the next week, devices provided at no cost, and funding

for transportation to and from sessions. The control group received the same low vision

therapy sessions, an exam by an optometrist, education on eye diseases and their prognosis,

eccentric viewing training, instruction on use of LVDs, psychological counseling, and social work

services. Four months after treatment was received, the study showed that there was a

significantly greater improvement in the treatment group across all visual ability domains.

Arbesman et al. (2013) showed that there was an improvement in activities of daily

living (ADLs) and IADLs when occupational therapy was used in conjunction with LVDs. During

treatment, participants were also taught problem solving skills, relaxation techniques, and

education regarding use of the LVDs. This was done in small groups, over several weeks, and

included homework assignments. Reading speed was improved and simultaneously,

dependence in ADLs and IADLs was reduced, which allows for greater participation in

meaningful activities.

Fok and Polgar and Shaw and Jutai (2011) and Leat and Fenggin Si and Gold and

Pickering and Gordon and Hodge (2017) conducted clinical studies in which the effectiveness of

two types of screen-centered low vision devices. Electronic video magnifiers and closed circuit

TVs (CCTV) are both expensive LVDs. The use of both of these devices showed improvement in

reading speed and participation, however, they were not examined in conjunction with
LVDS IN READING REHAB

occupational therapy, leaving these studies inconclusive to our recommendation that

occupational therapy will improve the benefits of LVDs when used together.

Smallfield et al. (2013) is concerned primarily with the role occupational therapy can

play in reading rehabilitation in a systematic review of the literature discussing low vision

interventions was made. Occupational therapy is unique in that it incorporates a multifaceted

approach to rehabilitation. Person, environment and occupation are combined with a focus

toward a person’s capabilities rather than their disabilities. LVDs, as with any assisted

technology, have the capacity to improve function but clients do not use these tools in

isolation. While the use of LVDs alone prove to be effective in improving client’s ability to read

versus without a device, the research is limited. Research designs lacked randomization and

control groups and many studies compared the effectiveness of LVDs versus no treatment and

no device which weakens its internal validity (Smallfield et al., 2013). Smallfield et al. (2013)

concluded that the gap occupational therapists fill in reading rehabilitation is teaching and

instructing in the correct usage of these technologies and most importantly, helping them

incorporate their use into their everyday routines.

Discussion

As vision deteriorates, reading ability is the most severely affected occupation since an

inability to read also affects the individual’s participation in so many other meaningful and

necessary occupations (Hamade et al., 2016). Low vision devices on their own can be helpful in

improving reading participation in people living with low vision, but the literature shows that

the devices are much more effective when coupled with occupational therapy (Stelmack et al.,

2012). This includes adaptation of the person’s home or work environments, with simple
LVDS IN READING REHAB

strategies like improving lighting, reducing glare, and replacing some household items with

large-print items, such as clocks, calendars, and timers.

The LVD that allowed the greatest level of improvement in reading, which was

measured by reading speed, was video magnification. There are different styles of video

magnification available, from stationary devices for home use to portable devices that can fit

into a pocket or purse. For the home or workspace, a system will be connected via personal

computer or television use, with smaller devices for travel that resemble mobile phones or

tablets. The larger devices have a camera that is pointed at the reading material, and the text

will be magnified onto the computer or TV screen. The camera can be moved over the item

being read, or the page can be moved in front of the camera. Aside from initial training of the

use for the device, little to no further training or occupational therapy would be necessary,

which possibly be the reason for its popularity among individuals with low vision (Jackson,

Schoessow, Selivanova & Wallis, 2017).

The other most widely utilized LVDs and strategies are: hyperocular glasses and other

magnifiers, microperimetric biofeedback, eccentric viewing training, CCTV, specialized

computer peripherals, built-in computer accessibility, and screen reader software. Also, many

patients living with low vision have even devised their own methods for adaptation without the

help of professionals, but because of this, the effectiveness of those methods isn’t clinically

measurable (Markowitz, 2006).

Though age-related macular degeneration (AMD), which is a loss of the central visual

field, is the leading cause of vision loss in older adults, a technique specific for peripheral

viewing training called eccentric viewing, has not been shown to be a consistently effective
LVDS IN READING REHAB

method. This is likely due to an unregulated training standard of practice among therapists

(Markowitz, 2006). There are also challenges facing individuals using technological devices for

improving reading speed and accuracy. Many of these LVDs involve maintenance, such as

updating or upgrading of software or hardware.

Our review found that LVDs are helpful and suggested that pairing LVDs with

occupational therapy can be even more beneficial to the client, but very few articles specifically

said which interventions are the most effective. This could be due to the fact that many other

factors must be considered, such as financial accessibility to LVDs, individual response to

different treatment methods, and individual desire to improve their functional vision and

independence. Single component methods of reading rehab yielded mixed results, while the

evidence yielded strong results in support of a multicomponent methods of incorporating LVDs

with occupational therapy.

With five randomized control trials, this review of the literature receives Level A, Class I

rating. It is our recommendation that a client with low vision who is exploring their options

among LVDs for their condition also seek out the help of an occupational therapist. By

implementing an LVD, an occupational therapist can increase the client’s functional reading

rehabilitation potential by teaching other strategies to improve their ability to read. This in turn

will allow the client to participate in other occupations that require reading for optimal

performance, such as reading for leisure, IADLs like managing finances, and reading the labels

of cleaning products. These are just a few of the vital tasks an individual needs to be able to

perform in order to retain their level of independence.

LVDS IN READING REHAB

References

2010 Census Shows 65 and Older Population Growing Faster Than Total U.S. Population. (2011).

United States Census Bureau. Retrieved from https://www.census.gov/newsroom/

releases/archives/2010_census/cb11-cn192.html.

Arbesman, M., Lieberman, D., & Berlanstein, D. R. (2013). Methodology for the systematic

reviews on occupational therapy interventions for older adults with low vision.

American Journal of Occupational Therapy, 67(3), 272-278.

DOI:10.5014/ajot.2013.007021

Fact Sheet: Aging in the United States. (2016). Population Reference Bureau. Retrieved from

https://www.prb.org/aging-unitedstates-fact-sheet/on.

Fok, D., Polgar, J. M., Shaw, L., & Jutai, J. W. (2011). Low vision assistive technology device

usage and importance in daily occupations. Work: A Journal of Prevention, Assessment

and Rehabilitation,39, 37-48. http://dx.doi.org/10.3233/WOR-2011-1149.

Hamade, N., Hodge, W. G., Rakibuz-Zaman, M., & Malvankar-Mehta, M. (2016). The effects of

low vision rehabilitation on reading speed and depression in age related macular

degeneration: A meta-analysis. PLoS ONE, 11(7).

DOI:http://doi.org.ezproxy.lib.utah.edu/10.1371/journal.pone.0159254

Huefner, K., Kaldenberg, J., & Berger, S. (2008). Vision-related issues facing older adults:

Occupational therapy’s role. Special Interest Section Quarterly: Gerontology, 31(2), 1-4.

Jackson, M. L., Schoessow, K. A., Selivanova, A., & Wallis, J. (2017). Adding access to a video

magnifier to standard vision rehabilitation: Initial results on reading performance and

LVDS IN READING REHAB

well-being from a prospective, randomized study. Digital Journal of Ophthalmology,

23(1), 1-10. doi:10.5693/djo.01.2017.02.001.

Leat, S., J., Fengqin Si, F., Gold, D., Pickering, D., Gordon, K., & Hodge, W. (2017). The

experience of a randomized clinical trial of closed-circuit television versus eccentric

viewing training for people with age-related macular degeneration. Journal of Visual

Impairment & Blindness, 111(4), 354-368.

Markowitz, M. (2006). Occupational therapy interventions in low vision rehabilitation. Canadian

Journal of Ophthalmology, 41(3[AT1] ), 340-347. DOI: https://doi.org/10.1139/I06-020

National Eye Institute. (n.d.). Retrieved March 22, 2018, from

https://nei.nih.gov/eyedata/vision_impaired/tables.

Smallfield, S., Clem, K., & Myers, A. (2013). Occupational therapy interventions to improve the

reading ability of older adults with low vision: A systematic review. American Journal of

Occupational Therapy,67(3), 288-295. doi:0.5014/ajot.2013.004929

Stelmack, J. A., Tang, X. C., Wei, Y., & Massof, R.,W. (2012). The effectiveness of low vision

rehabilitation in 2 cohorts derived from the veterans affairs low vision intervention trial.

Archives of Ophthalmology, 130 (9), 1162-1168.

Tunay, Z. O., Idil, A., Petricli, I. S., & Ozdemir, O. (2016). Low vision rehabilitation in older adults.

Turkish Journal of Ophthalmology, 46(3),118-122[AT2] . DOI:

http://dx.doi.org.ezproxy.lib.utah.edu/10.4274/tjo.68878

Vision Health Initiative (VHI): Data and Statistics. (2015). Centers for Disease Control and

Prevention. Retrieved from https://www.cdc.gov/visionhealth/data/national.htm.