Previous Section 7. Language and Communication Next Section 9. Central Pain
NEW Delivery Of Stroke Rehabilitation to Optimize Functional Recovery
NEW Delivery Of Stroke Rehabilitation to Optimize Functional Recovery

8. Visual and Visual-Perceptual Impairment

Recommendations and/or Clinical Considerations
8.0 Visual and Visual-Perceptual Impairments
  1. All individuals with stroke should be screened for central vision impairment, ocular motility disorders, visual field deficits, and visual perceptual disorders early after stroke as a routine part of the broader rehabilitation assessment process [Strong recommendation; Moderate quality of evidence].
  2. Individuals with stroke with suspected perceptual impairments (e.g., visuo-spatial impairment, agnosia, body schema disorders and apraxia) should be assessed using validated tools [Strong recommendation; Low quality of evidence]. 
  3. Individuals with stroke who have vision or visual-perceptual impairment, their family and caregivers, should receive education on visual-spatial impairment and other perceptual deficits as well as treatment recommendations and safety considerations [Strong recommendation; Low quality of evidence].
8.1 Vision Impairments
  1. Individuals with visual impairment impacting their ability to locate themselves and travel safely and independently either indoors or outdoors should receive training in compensatory techniques, including sighted guide, orientation to space, and mobility training in familiar and unfamiliar spaces [Strong recommendation; Moderate quality of evidence].
  2. Individuals with difficulties completing ADL and instrumental activities of daily living (IADL) activities related to visual impairments post-stroke should receive assessment and training from appropriate vision rehabilitation specialists when feasible [Strong recommendation; Moderate quality of evidence]. 
    1. Intervention should focus on the use of specialized compensatory techniques (such as scanning) and modifications to the task or environment such as increase of luminance/lighting or contrast [Strong recommendation; Moderate quality of evidence].
8.2 Visual-Perceptual Impairments
  1. Visual scanning training may be considered to improve spatial neglect [Strong recommendation; Moderate quality of evidence].
  2. Mirror therapy should be used to improve visual spatial neglect in the early-stage post stroke [Strong recommendation; Moderate quality of evidence].
  3. Eye patching of the non-affected hemi field (ipsilateral to the lesion) may be considered to improve visual spatial neglect reading and neglect symptoms [Strong recommendation; Low quality of evidence].
  4. Virtual reality may be considered to improve visual spatial neglect [Strong recommendation; Low quality of evidence]. 
  5. Limb activation may be considered to improve visual spatial neglect [Strong recommendation; Moderate quality of evidence]. 
  6. The use of prisms may be considered to expand the visual field and increase scanning abilities; however, there is no evidence of impact on functional performance [Strong recommendation; Moderate quality of evidence].

Refer to Rehabilitation, Recovery and Community Participation Following Stroke Part Three: Optimizing Activity and Community Participation following Stroke, Section 4 for information on return to driving.

Section 8 Clinical Considerations
  1. Body awareness training and movement interventions may be used to improve visual spatial neglect symptoms and activities of daily living. 
  2. Non-invasive brain stimulation may be considered to improve visual spatial neglect.  Note these interventions are not yet available/approved for use in Canada.
  3. Consider education on compensatory strategies to improve functional performance or comfort, such as unilateral translucent patching for double vision, binasal occlusion for spatial vision, environmental modifications or cues for neglect.
  4. For individuals with vision impairment following stroke, referral to a neuro-ophthalmologist or an optometrist experienced in post-stroke vision rehabilitation may be considered.
Rationale +-

Visual perceptual disorders are common following stroke, affecting an average of 65% of individuals with stroke in the acute stage of stroke. 196 These impairments can negatively affect an individual’s ability to process and interpret visual information, and may manifest as problems with depth perception, spatial awareness, and the ability to recognize objects or faces, which can hinder daily activities such as reading, driving, and navigating environments. As a result, individuals may experience increased frustration and anxiety, leading to reduced independence and social participation. The presence of neglect has been associated with both severity of stroke and age of the individual and the challenges posed by visual perceptual impairments have also been associated with longer lengths of hospital stay and slower recovery during inpatient rehabilitation.

Post-stroke visual impairment (VI) is a common but often under-recognized concern. It can manifest as decreased vision, diplopia, visual field deficits, eye movement disorders, and visual inattention or neglect or visual perception disorders. More than half of stroke survivors will experience vision impairment. 196 Individuals with post-stroke vision impairment often face a decline in their quality of life, reduced independence, increased depression, and higher chance of social isolation. 197 Additional challenges recognizing vision impairment can arise when patients have neurological or cognitive deficits, such as visual-spatial inattention and communication impairment, which can obscure the symptoms. Standardized screening has been shown to be feasible and to improve the detection of vision loss after stroke. 198,199

Limb apraxia is more common in those with left hemisphere involvement (28 – 57%) but can also be seen in right hemisphere damage (0 – 34%). 200 While apraxia improves with early recovery, up to 20 percent of those initially identified will continue to demonstrate persistent problems.  Severity of apraxia is associated with changes in functional performance.

Individuals with stroke have emphasized the importance of awareness that visual perceptual deficits can occur following stroke. They express that it can be difficult for an individual with stroke to notice or communicate visual or perceptual changes following stroke and thus highlight the importance of access to appropriate screening, assessment, management and education. Individuals with stroke also advocate for improved access to vision rehabilitation services. They note that these changes can greatly impact activities of daily living and participation in rehabilitation. For example, it can be difficult for individuals with stroke to fully participate in rehabilitation when experiencing diplopia.

Performance Measures +-

System Indicators

  1. Availability of inpatient and community-based education and resources for individuals with stroke experiencing visual perceptual deficits.
  2. Proportion of individuals experiencing visual-perceptual deficits following an acute stroke.

Process Indicators

  1. Proportion of individuals with stroke with documentation that an initial screening for visual perceptual deficits was performed as part of an initial rehabilitation assessment.
  2. Proportion of individuals with stroke with poor results on initial screening who then receive a comprehensive assessment by appropriately trained healthcare professionals.

Patient-Oriented Indicators

  1. Changes in quality of life for individuals with stroke and visual perceptual deficits measured at regular intervals during recovery and participation, and reassessed when changes in health status or other life events occur (e.g., at 60, 90- and 180-days following stroke).
Implementation Resources and Knowledge Transfer Tools +-

Resources and tools listed below that are external to Heart & Stroke and the Canadian Stroke Best Practice Recommendations may be useful resources for stroke care. However, their inclusion is not an actual or implied endorsement by the Canadian Stroke Best Practices team or Heart & Stroke. The reader is encouraged to review these resources and tools critically and implement them into practice at their discretion.

Health Care Provider Information

Resources for Individuals with Stroke, Families and Caregivers 

Summary of the Evidence +-

Evidence Table and Reference List 8

Visual perceptual disorders are common following stroke, affecting an average of 65% of patients in the acute stage of stroke. The most common type of visual perception disorder following stroke is visual neglect or inattention, affecting 14% to 82% of patients. Visual field loss is also common, affecting 5.5% to 57% of patients. 201

In a Cochrane review examining a wide-range of interventions for all forms of impaired perception following stroke (hearing, smell, somatosensation, touch, taste and/or vision post stroke), Hazelton et al. 202 included 18 RCTs (541 participants). Among the 7 RCTs specifically examining 12 rehabilitation interventions for visual perception disorders, interventions assessed included repeated figure drawing, computer-based games, and therapist-led functional activities. In 2 trials, a single 90-minute session was provided. In the remaining trials, sessions lasted 30 minutes and were provided 3-5 days/week for 4-6 weeks. Overall, rehabilitation interventions were not associated with significantly higher extended activities of daily living (EADL) scores compared with a control condition (Rivermead ADL: MD=0.94, 95% CI -1.60 to 3.48; 1 trial, n=33), nor were perception scores higher (Motor-Free Visual Perception Test: MD= -1.75, 95% CI -5.39 to 1.89; 1 trial, n=27). The certainty of the evidence associated with both outcomes was very low.

In a Cochrane review, specifically examining interventions to improve spatial neglect post stroke, Longley et al. 203 included 65 RCTs (1,951 participants). A wide range of interventions were examined including visual interventions (e.g., visual scanning training, half-field eye patching), prism adaptation, body awareness interventions (e.g., limb activation, trunk rotation, mirror therapy), mental function interventions (mental imagery, virtual reality training, and general cognitive rehabilitation), movement interventions (e.g., robotic upper extremity treatment, constraint-induced movement therapy, and visuomotor feedback training), non-invasive brain stimulation (NIBS), electrical stimulation (e.g., transcutaneous electrical nerve stimulation [TENS], functional electrical stimulation [FES] and EMG-triggered electrical stimulation), and acupuncture. The primary outcome was performance of ADL. Visual interventions were not associated with significantly better ADL scores at one month post intervention compared with a control condition (SMD= -0.04, 95% CI -0.57 to 0.49; 2 trials, n=55), or immediately post intervention (SMD=-0.15, 95% CI -0.6 to 0.3; 3 trials, n=75), nor were they associated with significantly greater improvement in measures of neglect at either one month or immediately post intervention. Similarly, prism adaptation, and NIBS were not associated with significant improvement in performance in ADL or measures of neglect. Interventions that were associated with significant improvement in ADL performance and neglect were body awareness interventions, and electrical stimulation with devices, while no data were available for the primary outcome for mental function interventions, movement interventions, or acupuncture.

A Cochrane review 204 examining interventions associated with the rehabilitation of visual field deficits post-stroke to improve ADL performance, was unable to draw firm conclusions as limited data were available for pooled analysis. Among the 20 RCTs, data were available for one small trial indicating that visual restitution therapy had no effect on functional outcome, the primary outcome. Data were available from two trials of compensation (scanning), which also suggesting that therapy had no effect on extended activities of daily living. However, there was limited low-quality evidence that compensatory scanning training improved quality of life. Similarly, data from single trials of compensative interventions (prims) and assessment by an orthoptist were not associated with significant improvements in ADL performance.

A systematic review included 238 inpatients from 5 RCTs with unilateral neglect associated with a stroke sustained within the previous month. 205 Interventions were initiated during inpatient rehabilitation and examined the addition of mirror therapy to routine rehabilitation +/- other co-interventions with sham mirror therapy or no mirror therapy plus routine rehabilitation +/- other cointerventions.  Mirror therapy was associated with significant improvement in standardized measures of spatial neglect (SMD=1.62, 95% CI 1.03–2.21) and ADL (SMD=2.09, 95% CI 0.63–3.56) at the end of treatment. There is limited evidence from a few small trials of the benefits of eye patching, 206,207 virtual reality, 208,209 and limb activation.210

Non-invasive brain stimulation has been used successfully in the rehabilitation of visual impairment. Kim et al. 211 randomized 27 patients admitted for inpatient rehabilitation, with visuospatial neglect to receive repetitive transcranial magnetic stimulation (rTMS). Patients were randomized to receive 10, 20-minute sessions over 2 weeks of 1) low-frequency (1Hz) rTMS over the non-lesioned posterior parietal cortex (PPC), 2) high-frequency (10Hz) rTMS over the lesioned PPC, or 3) sham stimulation. Although there were no significant differences between groups in mean changes in Motor-Free Visual Perception Test, Star Cancellation Test or Catherine Bergego Scale, there was a significant difference among groups in Line Bisection Test change scores (p=0.049). Post-hoc analysis indicated the improvement was significantly greater in the high-frequency rTMS group compared to sham-stimulation group (-36.9 vs. 8.3, p=0.03). Additionally, improvements in mean Korean-Modified Barthel Index scores in both the high and low frequency groups were significantly greater compared to those in the sham stimulation group (p<0.01 and p=0.02, respectively). Yang et al. 212 reported improvements in mean Behavioural Inattention Test (BIT)-Conventional, following treatment with rTMS, when treatment was combined with a sensory cueing device worn on the left wrist.

Sex & Gender Considerations

There is limited research specifically addressing sex differences in vision rehabilitation outcomes following stroke.

Stroke Resources
Previous Section 7. Language and Communication Next Section 9. Central Pain