The theme of Orthoptics Awareness Week (5-9 June 2023) is: ‘Connect. Collaborate. Care’. To bring the campaign to life, Orthoptics Australia has teamed up with Insight to highlight local orthoptists who work with other health professionals to enhance eye healthcare accessibility both clinically and in the research sector.
TRAUMATIC BRAIN INJURY AND ORTHOPTIC TREATMENT
Working with TBI patients with vision and eye disorders often involves joint consultations with other allied health professionals to gain insight into each person’s difficulties and the impact on their rehabilitation.
In 1984 Westmead Brain Injury Unit was first established to specifically provide rehabilitation to patients who had received a traumatic brain injury (TBI) from incidents such as motor vehicle accidents. I was fortunate to be working in the eye clinic at Westmead Hospital at that time and became involved in the unit assessing and treating TBI patients.
Fast forward to 2001, and I commenced a private orthoptic practice in northwest Sydney and started seeing these brain injury patients in a private capacity as well as seeing the usual ocular motility conditions that an orthoptist treats in adults and children.
Working with TBI is extremely rewarding. Their eye problems are usually quite complex and challenging with many co-morbidities, particularly as the incidence of eye problems in TBI is found to be 70%. TBI will commonly involve damage to the cerebral cortex, as well as the brainstem and cerebellum causing visual changes unique to these neurological areas. Conditions include ocular motility disorders causing diplopia from cranial nerve palsies, nystagmus or eye movement paralysis from brainstem/cerebellum damage in association with visual field defects such as homonymous hemianopias and visual perception issues from damage to the cerebral cortex.
Other eye problems can also include keratoconus, which can be accelerated from the oxidative stress of the interventions for the TBI. The development of myopia can also be strongly associated with high-speed motor vehicle accidents. It is not uncommon for TBI patients to also develop optic atrophy.
As such, assessment of this patients is multifactorial and often requires lengthy consultations as well as involvement of ophthalmology and optometry. I am fortunate to have good access to both professions in my practice.
Assessment of a TBI patient’s vision and eye disorders always involves the initial review of reports or conversations with other allied health professions such as occupational therapists, speech therapists, physiotherapists, rehabilitation physicians, psychologists and neuropsychologists prior to the consultation so that you can be fully prepared to assess the patient. This can often involve joint consultations with other allied health professionals present for the consultation to gain insight into the patient’s difficulties and their impact on their rehabilitation.
These TBI patients often have speech difficulties such as aphasia and cognitive deficits with short-term memory issues and lack of insight into the seriousness of their neurological condition.
Treatment of eye conditions will often involve the prescribing of glasses, fusion training, saccadic and scanning eye training. Any home exercises given are often supervised by carers or allied health providers such as the occupational therapists in conjunction with in-clinic treatment.
The legal ability to meet the vision standards for driving often arises when seeing these patients, as the typical patient seen with TBI is a male in their early 20s who are keen to return to driving. Vision standards for driving need to be carefully scrutinised and guarded advice given to all health professionals involved. An on-road assessment maybe required in a joint capacity with a driver trained occupational therapist.
With their specialised knowledge of eye disorders occurring in TBI, an orthoptist plays an important role working within the multidisciplinary team.
PREVENTING THOSE WITH DUAL IMPAIRMENTS FROM SLIPPING THROUGH THE CRACKS
Orthoptists are collaborating with speech pathologists to support effective communication to ensure patients with dual visual and communication impairments receive appropriate care.
As healthcare professionals, communicating effectively with patients is essential. However, what would you do if a patient has trouble explaining what is wrong with their vision? Perhaps they’ve had a stroke and now have aphasia (a language impairment), or they’ve struggled with communication since they were young, and now at the eye clinic, they have difficulty answering your questions. When you finally manage to work out the nature of their vision impairment, what if they cannot understand the diagnosis and treatment options? This is a challenging situation, but is the reality for many people who live with communication impairments and the healthcare professionals who care for them.
My research project aims to bridge the gap between individuals with dual impairments and access to eyecare. Trying to tackle this issue requires partnerships with multidisciplinary team members. Our team consists of orthoptists and speech pathologists, and we are working to improve the quality of care provided to this population.
We conducted a review of the literature and found that communication partner training is extremely beneficial for healthcare professionals as it increases their confidence and competence when interacting with people with communication impairments. However, we did not find any studies that included eyecare professionals or patients with dual impairments.
Many training programs also use visual cues as a compensatory strategy for verbal communication impairments, which may not be ideal for patients with both impairments. This is why our starting point for this project was working with orthoptists and speech pathologists who currently interact with people with dual impairments.
We first conducted a survey to obtain a snapshot of practice of orthoptists in relation to managing patients with dual impairments in clinic, what supportive communication strategies they’re using in clinical practice and what else they need to provide person-centred care. We found most participants felt they had not received sufficient training regarding supported communication and that there is an “absence of resources targeted specifically to orthoptists”.
This study was followed by focus groups to gain a deeper understanding of their experiences in interacting with people with dual impairments. We recruited orthoptists and speech pathologists to understand how these professions interacted with individuals with dual impairments. Key issues they raised included the importance of interdisciplinary collaboration and the lack of training available. Participants highlighted the effectiveness of having a speech pathologist present at an orthoptic assessment and vice versa. With these collaborative consultations, it is also an opportunity for clinicians to learn from each other and implement these skills in their future practice. Regarding training, participants who work in general practice all reported not having training in supported communication despite also seeing patients with dual impairments in their clinical practice.
The last phase of the project involves working on potential resources to better support eyecare professionals in communicating effectively with this population. The literature shows that the adult population with communication impairments has been the most studied, so we decided to collaborate with a research team that developed an online self-guided training programme (interact-ABI-lity; abi-communication-lab.sydney. edu.au/courses/interact-abi-lity/) that covers communication changes after acquired brain injury (including aphasia, dysarthria and cognitive- communication impairments).
Through further studies we hope to determine whether this program helps orthoptic students gain greater knowledge of communication impairments and effective strategies and explore any other modifications needed to provide eyecare professionals with relevant training. Although there is currently a lack of training for the paediatric and lifelong communication disability populations, we hope that by using interact-ABI-lity as a starting point, in future we can adapt it further for these other populations, and that speech pathologists can also benefit from knowing about the impact of vision on their clinical practice. We hope through this project, eyecare professionals will be better prepared to support patients with dual impairments, and their equitable, positive access to person centred care.
NOTE: co-authored by A/Prof Emma Power and Dr Amanda French.
THE COMPLEXITIES OF CARING FOR ACQUIRED BRAIN INJURY PATIENTS
Patient-centred care for patients with an acquired brain injury requires a multidisciplinary approach, but not all hospitals and rehabilitation centres have access to orthoptists or eyecare services. The development of resources for non-eyecare health providers is helping overcome this problem.
An acquired brain injury (ABI), such as stroke can occur at any age, but in most cases, incidence is greater in older patients and therefore more likely to have a pre-existing ocular condition present on hospital admission. For acute ABI, initial investigations are performed by emergency medical personnel, with a range of visual problems often remaining unrecognised as they are not targeted by existing neurological screening tools or protocols. Research reports that up to 73% of stroke survivors have some form of acquired or pre-existing visual impairment1, supporting the need for better screening processes to identify visual problems in these patients.
ABI is complex, with both motor and sensory defects possible. Patient-centred care is best supported by a multi-disciplinary team of healthcare practitioners, each with a specific expertise. Orthoptists have specialised skills that aid in recognition and management of neurological and age-related ocular conditions, which is advantageous in team care of patients who have an ABI, including stroke.
Unfortunately, not all hospitals or rehabilitation facilities looking after ABI patients have direct access to orthoptic or other eyecare services. Therefore, as an outcome of my PhD, there now exists a specifically designed and validated Vision Defect in Stroke Screening Tool (VDiSST)2 and an accompanying eLearning module titled: ‘Understanding the Vision Defect in Stroke Screening Tool’. The agenda for both resources is to enable non-eyecare health practitioners, in the absence of orthoptic and other eyecare services, the ability to identify and refer for further assessment, a range of pre-existing and newly acquired vision impairments in survivors of brain injury.3
Patient-centred care in ABI requires a multidisciplinary approach, therefore when designing and evaluating these two vision screening resources, it was important to collaborate and discuss level of need and impact with a range of stakeholders which include healthcare practitioners working in this area. Connections were facilitated through a variety of organisations, including the Agency of Clinical Innovations (ACI), the University of Technology Sydney (UTS), NSW Local Health Districts and Liverpool University. Specific health professions consulted, recruited and then contributing to data collection, throughout included nurses, occupational therapists, physiotherapists, speech pathologists, and orthoptists.
The vision screening tool was used in a pilot project run at UTS to promote interdisciplinary collaboration. Using a stroke scenario, students from five disciplines (nursing, speech pathology, physiotherapy, orthoptics and pharmacy) were guided to provide collaborative care to a young stroke survivor. Once graduated and working within their intended profession, it’s hoped this experience would encourage them to continue working collaboratively and not in siloes because they don’t fully understand the role of other disciplines or how they can help each other’s overall care of a stroke survivor. Feedback accumulated from students from all disciplines participating in the pilot found this a rewarding project. Currently, two publications and discipline specific accepted conference presentations promote the success of this project.
While each health profession does have its own area of speciality, there are times when our interests overlap and learning from each other is part of lifelong education. As orthoptists if we can actively communicate and make others aware of expected or actual visual limitations and, in turn, collaboratively learn from others’ disciplines for communal patients, this would serve to only improve everyone’s ability to provide efficient patient care ensuring successful outcomes.4-5
1. Rowe FJ, Hepworth LR, Howard C, Hanna KL, Cheyne CP, Currie JJPo. High incidence and prevalence of visual problems after acute stroke: An epidemiology study with implications for service delivery. 2019;14(3):e0213035.
2. Courtney-Harris M, Jolly N, Rowe F, Rose K. Validation of a vision-screening tool for use by nurses and other non-eye care health practitioners on stroke survivors. Contemporary nurse : a journal for the Australian nursing profession. 2022;58(4):276-284. doi:10.1080/103 76178.2022.2104334
3. Courtney-Harris MD. The evaluation of a vision screening tool for the detection of vision problems in stroke survivors. University of Technology Sydney; 2022. Thesis.
4. Lucas C, Power T, Kennedy DS, Forrest G, Hemsley B, Freeman-Sanderson A, Courtney-Harris M, Ferguson C, Hayes C. (2020) Conceptualisation and Development of the RIPE-N model (Reflective Interprofessional Education – Network model) to enhance interprofessional collaboration across multiple health professions. Reflective Practice 2020, 21(5); 712-730 9
5. Hayes, Power, T., Forrest, G., Ferguson, C., Kennedy, D., Freeman-Sanderson, A., Courtney-Harris, M., Hemsley, B., & Lucas, C. (2022). Bouncing off Each Other: Experiencing Interprofessional Collaboration Through Simulation. Clinical Simulation in Nursing, 65, 26–34. https://doi.org/10.1016/j.ecns.2021.12.003