Quiz 2 Flashcards
3 Component Model of Vision
Considers:
Visual Integrity
Visual Efficiency
Visual Information Processing
1 Component Model of Vision
Only evaluates visual integrity (acuity, refraction, & eye-health)
Not sufficient to detect vision problems that are prevalent in peds population
Visual Integrity
- Visual Acuity: The ability to see fine detail
- Refractive Error: The optical characteristics of the eye (myopia, hyperopia, astigmatism)
- Eye Health: health of all components of the visual system from the eye to the brain
Visual Efficiency
Accommodation: the ability to change focus from near to far objects
Binocular Vision: the ability to use both eyes in a coordinated manner
Eye Movements: the ability to maintain steady fixation on an object, look from object to object, and follow moving objects
Visual Information Processing
Visual Spatial: ability to understand right and left on one’s own body
Visual Analysis: ability to analyze and interpret visual stimuli
Visual Motor Integration: ability to accurately reproduce a visual stimulus
Eye Care Professionals
Opitcian: helps select appropriate eyeglasses frame ( no training to perform clinical testing)
Ophthalmologists: diagnose and treat using meds and surgery
Optometrists: MD, use 3 component model
Down Syndrome & ASD vision problems
commonly have refractive error, accommodative problems, and strabismus
Convergence Insufficiency Survey Vision Screening
CISS score of > 16 suggests visual inefficiency, vision screening should be considered
CISS score by itself should not be the basis for concluding that a vision problem is present
Visual Acuity Problems
Myopia: nearsightedness (far away objects are blurred but near objects are clear)
Hyperopia: farsightedness (nearby objects are blurry) most common refractive error in childhood
Astigmatism: vision is blurred at both distance and near
Amblyopia: lazy eye
Ocular Development
-structures that will be eyes appear at 4 weeks gestation
-by 7 weeks gestation they form into eyes
Coloboma: pupils look like keyholes; cleft like defect in eyes (have CHARGE syndrome) -bludging small eyes
Hypertelorism: abnormally wide spaced eyes
Intrauterine infections can cause cataracts,
glaucoma or inflammation of the retina
Development of Visual
Skills
At 3 months:
-infant can fix a steady gaze and track a small target at near range and eyes become straight at this age
-Visual acuity improves fivefold in the first 6 months
By 3-4 years
-vision can be objectively measured by
identifying a series of pictures at a distance for
20/40 vision or better
By 6 years old
-visual acuity should be 20/30 or better and if
possible should be measured with letters
Binocularity
Determine eye alignment and how well eyes work together as a team: skill and endurance
Signs of dysfunction:
-Struggle with visual tasks
-Take long time to complete a task
-Normal amount of time but with discomfort
-Avoid tasks
Accommodation
ability to change the focus of eyes so that objects at different distances can be seen clearly
Accommodative disorders can interfere with any activity that requires visual concentration on small objects or print at a close distance
Ocular Motility
Determine the range that the eyes can move
-Test R and L eyes separately
-Should be able to go full range when follow target (held 16 inches from face) in circle
Saccades
- Ability to move eyes to scan environment and track while reading
- Rapid changes in fixation in the visual field from one point to another
- Tested by direct observation for overshooting or undershooting
- child is asked to look back and forth repeatedly between two targets (8-10
inches apart) - Targets should be approximately 12 inches in front of the child’s face
- Assess in horizontal, vertical and diagonal planes
Pursuits
Pursuits: is slow, coordinated movement of both eyes following a moving target
* Child is asked to follow a moving target that is 12-16 inches from the child’s face
* Assess in horizontal, vertical, and diagonal planes
* Eyes should be tested separately then together
* Test: direct observation for tracking of object
* 4 y/o will probably move head, but if asked, should be able to follow target with
eyes
Abnormal Ocular Motility
- Head movement
- Jump of lines during reading
- Automatic use of head
(unacceptable after age 6) - Undershoots (does not go far enough)
- overshoots (too far and come back (unacceptable after age 7)
Visual-Motor Skills
ability to
integrate visual information
processing skills with fine motor skills. Eye-hand coordination
Visual analysis skills
ability to analyze and discriminate visually presented information,
determine whole without
seeing parts.
2 skills of visual spatial abilities
Visual Spatial analysis:
-spatial properties of objects are analyzed (eg. Chess game)
Visual Construction:
-A perceptual activity with a motor response that includes drawing and
assembling
-replication of spatial aspects of objects
-Copying drawings/models
Vestibular Ocular Reflex (VOR)
-Responsive at birth
-Maintains stable vision on retina during head movements
-Eye movements are fastest and most frequent
movements made by body
-Provides eye-hand coordination
Nystagmus
rhythmic oscillation of eyes that occurs during or after head movement (Rapid jiggling back and forth (mainly horizontal) of the eyes)
-Decreased eye head control
-Poor tolerance of visual motion
-Dysfunction can have direct effect on efficiency of reading and school performance
-Causes: small optic nerve, underdeveloped fovea, variety of rods and cones abnormalities
-Can be latent (only present with occlusion of one eye)or manifest (constant
at all times)
Oscillopsia
perception that objects are bouncing during
head movements (bilateral vestibular dysfunction)
Post rotary nystagmus testing
-Position child with head tucked and eyes closed
-Spin for 8-10 repetitions
-Observe for nystagmus immediately after
-Abnormal-
no response,
hypo- response, asymmetry
hyper-response ( greater than 18 seconds)
Amblyopia
unilateral in which a “healthy” eye is turned off or ignored by the brain
-Treated with glasses, patching, or eye drops to blur the vision of the better seeing eye encouraging the
brain to use and develop vision in the amblyopic
eye
Strabismus
-Esotropia: cross- eyed, eyes turn in
-Exotropia: cross -eyed , eyes turn out
Hyper-deviation: vertical misalignment of eyes
common with CP
surgery can be done to adjust
Eye patching before age 6: 2hrs a day for 3-6 months
Cataract
first appears as a white spot in the pupils or both eyes. If untreated, it will cause
amblyopia
If cataract is larger than 3mm then surgery is
required
Better outcomes in infants if surgery is done
before 6 weeks of age
Optic nerve hypoplasia
small thin optic nerve transmits impaired
information to the brain resulting in decreased vision
-uncorrectable with glasses. Often associated with other developmental disabilities
Retinopathy of prematurity
most common cause of retinal damage in infants.
-Important to treat these infants to preserve
their visual function.
-Results from vascular damage to the retina
Cortical visual impairment (CVI)
-decreased visual response due to a neurological problem affecting the visual part of the brain
-Children with CVI present with visual attention
deficits that range from mild to severe
-Parents notice that their infant responds to light
and dark but may not look directly at parents’ face
-Child is able to track somewhat but appears to look over items not at them
-These children can see better peripherally if the
object or they are moving
Blindness
Visual acuity of 20/200 or worse in the better eye
with correction
conductive hearing impairment
dysfunction in outer or middle ear
sensorineural hearing impairment
dysfunction caused by damage in inner ear or auditory nerve
3 Hidden Senses
Vestibular:
info about body movement and head position through inner ear; tells us the type of movement happening (fast vs. slow) helps coordinate movement of eyes, had, & body; affects balance, muscle tone, arousal, emotional state, auditory skills, bilateral integration
Proprioceptive:
info about what body is doing where body parts are in space; affects how much force we put into movement, walk without looking at their feet
Interoception:
internal organs; the sense that helps you understand the “internal state” of your body
ex. hunger, heartbeat, mood, arousal
Dysfunction in this system:
Person cannot identify whether they are hungry, full, hot, cold, thirsty
Adaptive response
a state in which brain appropriately
organizes & processes incoming sensory information to
organize successful and goal-oriented action on the environment
Decreased Connections in Limbic
System
-Hippocampus: is involved in the formation of new memories and is also associated with learning and emotions
– Amygdala- Shown to play a key role in the processing of emotions
■ Rage, aggression, flight/fright, hormone, sexual behaviors
– Septum- has been implicated as a vital part of the circuitry for decision making and reward-related behavior.
– PreFrontal cortex- with connections to both the “emotional” limbic system and the “cognitive” prefrontal cortex. … These actions are taken as part of maladaptive approaches to control, avoid, or regulate painful emotions
– Cingulate gyrus- the curved fold covering the corpus callosum. A component of the limbic system, it is involved in processing emotions and behavior regulation. It also helps to regulate autonomic motor function.
Other regions to consider:
■Parietal cortex: sensory integration, object manipulations,
processing of touch sensation
■ Temporal Lobe: vision, memory, sensory input, language,
emotion, and comprehension
4 LEVELS OF SENSORY
INTEGRATION
Level- 4
Academic Readiness (6 years old)
Level- 3
Perceptual-Motor (3 years old)
Level- 2
Foundation of Perceptual Motor (6-24
months)
Level - 1
Primary Sensory System (2 months old)
Types of Sensory Integration Problems (Ayres approach)
- Sensory reactivity
- Sensory discrimination/perception
- Vestibular-bilateral function
- Praxis
Sensation seeking
– High neuro threshold + active self reg strategy
– Enjoys and generates extra sensory input) Adding spice to already
seasoned food
Low registration
– High neuro threshold + passive self-reg strategy
– Notices sensory stimuli much less than others, doesn’t’t get the jokes
as quick
Sensation avoiding
– Low neuro threshold + active self-reg strategy
– Bothered by input more than others, only will eat familiar foods
Sensory sensitivity
– Low neuro threshold + passive self reg strategy
– Detects more input than others. Eg. Child is afraid of heights &
experiencing discomfort
Habituation
the process that represents to the nervous system that something familiar has occurred
Sensitization
– The nervous systems mechanism that enhances potentially important stimuli
– detects harm or danger in a situation
SENSORY PROCESSING
DISORDERS (SPD)
- SMD- Sensory Modulation Disorder
- SDD- Sensory Discrimination Disorder
- SBMD- Sensory Based Motor
Disorder
Sensory Modulation/Sensory
Reactivity
- Sensory hypereactivity (sensory defensiveness)
- Sensory over-responsiveness (Aggression, Impulsivity, Irritability)
- Sensory registration/hypoactivity (doesn’t cry when injured, quiet, withdrawn, unaware of body sensations)
- Over-Reactiveness (food textures, fragrance, grass/sand, fingernails cut, background noise)
- sensory seeking (on the move, bumping into things, fixates on objects)
Sensory Discriminate Disorder (SDD)
– Difficulty following directions and gets easily lost
– Aversion to puzzles or other visual games
– Frustration when unable to differentiate visual or auditory
signals
– A need for directions to be repeated
Treatment
– Improve relationship between child’s body and people and space
– Improve motor planning and organization of behavior
– Increase somatosensory input
while child is navigating 3-D space
– Increase ability to discriminate force
Sensory Based Motor Disorder
(SBMD)
– Difficulty learning new motor skills
– Often trips or bumps into people or things
– Is clumsy awkward or accident prone
– Struggles with multiple step
directions
– Poor ball handling skills
– Difficulty performing self-care tasks
Treatment
– Novel activities
– Games that involve specific directions of body parts in space
– Goal of treatment is to have the child independently plan and execute
projected action sequences
Wilbarger Brushing Program
Purpose: change sensory thresholds
■ Deep pressure strokes down arms, legs, back, (palms of hands & bottom of feet – based on clinical judgment). About 2 minutes
■ Joint compression in this order – arms, legs, back
■ Gentle traction to fingers and toes
■ Every 2 hours
■ Good to do before transitions
Contraindications:
■ Do not brush babies younger than 4 months
■ Do not brush on rashes, eczema
■ Dermatographia – skin shows large reddened areas when exposed to abrasions
NDT techniques help facilitate:
facilitation of typical motor patterns is combined with simultaneous inhibition of atypical movements
Treatment should:
Treatment should not follow typical developmental sequence regardless of age and physical condition of
child
– whatever function child requires most urgently is priority of established treatment goals
Primary impairments
components representing major constraints on movement and posture
Secondary impairments
challenges in function that arise “secondarily” from atypical interaction between neuromuscular system and
structural/functional changes in musculoskeletal
system
Indicators of dysfunction: Range of
movement and dissociation of movement
contractures, deformities, log rolling, bunny hopping
Indicators of dysfunction: Alignment
and patterns of weight bearing
posterior pelvic tilt, anterior pelvic tilt, asymmetrical posture, narrow or widened base of support
Indicators of dysfunction: Muscle tone
antigravity movements, limbs feel heavy on PROM, presence of involuntary movements or fluctuations in muscle activation, increased degree of tension in muscles, resistance to PROM
Indicators of dysfunction: Postural tone
excessive stiffness in trunk, excessive flopiness in trunk when attempting to sustain posture against gravity
Indicators of dysfunction: Balance and postural control
narrow or widened base of support, use of compensatory patterns
Comprehensive occupational therapy evaluation should include (cerebral palsy):
– Evaluation of oral-motor and feeding skills
– Gross and fine motor skills
– Sensory issues
– Social–emotional factors
– Cognitive skills
Postulates Regarding Change Relating to Range of Motion and Dissociation of Movement
-If the therapist prepares the client’s muscle length and joint ROM with various forms of handling, potential to increase muscle activation is facilitated.
-If the therapist provides handling to promote weight shifts and transitional movements, alignment and dissociation of joint segments are supported as the child moves in and out of positions with proper alignment.
Spastic CP
Resistance to stretch, stiffness in muscles
* Velocity dependent
* Often associated with clonus + extensor plantar response,
persistent primitive reflexes
* When you move the child: you feel a “catch” in ROM
* Impacts force of movement and movement regulation
Dyskinetic CP
Excessive abnormal movements with movement initiation
Athetoid: fluctuation in muscle tone
Slow writhing, involuntary
movements combined with
abrupt/jerky movements
Choreoathetoid:
* random & constant fluctuations from low-high tone (usually more proximal)
* Sustained twisted posture absent at
rest, triggered by action
Dystonic: more predictable
postures at stereotyped movements
Ataxic CP
- Poor balance & coordination
- Children may show shifts in muscle tone with quad distribution
- More success in directing voluntary movement
- May have tremors
- Great difficulty with balance, coordination, maintaining head, trunk and shoulder alignment
CP Primary Impairments
- Muscle weakness/hypotonicity
- Muscle tightness/hypertonicity
- Spasticity
- Involuntary movement
- Weakness of eye muscles
- Abnormal tone in facial muscles
- Impaired sensation in impacted limbs
- Possible seizure disorder
CP Secondary Impairments
- Joint contractures
- Unsteady gait
- Impaired visual processing, hearing,
speech - Difficulty with bladder/bowel control
- Breathing problems due t
posture/weakness - Skin integrity/pressure sores
- Difficulty feeding/swallowing
Gross Motor Functions
Classification System
( GMFCS) Level 1
Least Severe
* Can walk indoors and outdoors and climb stairs without using hands
for support
* Can perform usual activities such as running and jumping
* Has decreased speed, balance and coordination
Gross Motor Functions
Classification System
( GMFCS) Level 2
- Can climb stairs with a railing
- Has difficulty with uneven surfaces, inclines or in crowds
- Has only minimal ability to run or jump
Gross Motor Functions
Classification System
( GMFCS) Level 3
- Walks with assistive mobility devices indoors and outdoors on level
surfaces - May be able to climb stairs using a railing
- May propel a manual wheelchair and need assistance for long
distances or uneven surfaces
Gross Motor Functions
Classification System
( GMFCS) Level 4
- Walking ability severely limited even with assistive
devices - Uses wheelchairs most of the time and may propel
own power wheelchair - Standing transfers, with or without assistance
Gross Motor Functions
Classification System
( GMFCS) Level 5
Most Severe
* Has physical impairments that restrict voluntary control of movement
* Ability to maintain head and neck position against gravity restricted
* Impaired in all areas of motor function
* Cannot sit or stand independently, even with adaptive equipment
* Cannot independently walk but may be able to use powered mobility
Ontario Motor Growth Surveys (OMG)
-A longitudinal study designed to chart the gross motor progress children with cerebral palsy
-The 5 OMG curves represent the
expected patterns of motor
development and function of children
with CP based on current and
available treatment.
