Interventions for visual field defects in patients with stroke

Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Buchanan House, Cowcaddens Road, Glasgow, UK, G4 0BA.
Cochrane database of systematic reviews (Online) (Impact Factor: 6.03). 10/2011; DOI: 10.1002/14651858.CD008388.pub2
Source: PubMed


Visual field defects are estimated to affect 20% to 57% of people who have had a stroke. Visual field defects can affect functional ability in activities of daily living (commonly affecting mobility, reading and driving), quality of life, ability to participate in rehabilitation, and depression, anxiety and social isolation following stroke. There are many interventions for visual field defects, which are proposed to work by restoring the visual field (restitution); compensating for the visual field defect by changing behaviour or activity (compensation); substituting for the visual field defect by using a device or extraneous modification (substitution); or ensuring appropriate diagnosis, referral and treatment prescription through standardised assessment or screening, or both.
To determine the effects of interventions for people with visual field defects after stroke.
We searched the Cochrane Stroke Group Trials Register (February 2011), the Cochrane Eyes and Vision Group Trials Register (December 2009) and nine electronic bibliographic databases including CENTRAL (The Cochrane Library 2009, Issue 4), MEDLINE (1950 to December 2009), EMBASE (1980 to December 2009), CINAHL (1982 to December 2009), AMED (1985 to December 2009), and PsycINFO (1967 to December 2009). We also searched reference lists and trials registers, handsearched journals and conference proceedings and contacted experts.
Randomised trials in adults after stroke, where the intervention was specifically targeted at improving the visual field defect or improving the ability of the participant to cope with the visual field loss. The primary outcome was functional ability in activities of daily living and secondary outcomes included functional ability in extended activities of daily living, reading ability, visual field measures, balance, falls, depression and anxiety, discharge destination or residence after stroke, quality of life and social isolation, visual scanning, adverse events and death.
Two review authors independently screened abstracts, extracted data and appraised trials. We undertook an assessment of methodological quality for allocation concealment, blinding of outcome assessors, method of dealing with missing data, and other potential sources of bias.
Thirteen studies (344 randomised participants, 285 of whom were participants with stroke) met the inclusion criteria for this review. However, only six of these studies compared the effect of an intervention with a placebo, control or no treatment group and were included in comparisons within this review. Four studies compared the effect of scanning (compensatory) training with a control or placebo intervention. Meta-analysis demonstrated that scanning training is more effective than control or placebo at improving reading ability (three studies, 129 participants; mean difference (MD) 3.24, 95% confidence interval (CI) 0.84 to 5.59) and visual scanning (three studies, 129 participants; MD 18.84, 95% CI 12.01 to 25.66) but that scanning may not improve visual field outcomes (two studies, 110 participants; MD -0.70, 95% CI -2.28 to 0.88). There were insufficient data to enable generalised conclusions to be made about the effectiveness of scanning training relative to control or placebo for the primary outcome of activities of daily living (one study, 33 participants). Only one study (19 participants) compared the effect of a restitutive intervention with a control or placebo intervention and only one study (39 participants) compared the effect of a substitutive intervention with a control or placebo intervention.
There is limited evidence which supports the use of compensatory scanning training for patients with visual field defects (and possibly co-existing visual neglect) to improve scanning and reading outcomes. There is insufficient evidence to reach a conclusion about the impact of compensatory scanning training on functional activities of daily living. There is insufficient evidence to reach generalised conclusions about the benefits of visual restitution training (VRT) (restitutive intervention) or prisms (substitutive intervention) for patients with visual field defects after stroke.

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Available from: Fiona Rowe, Oct 23, 2014
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    • "Spontaneous recovery of vision is unlikely to occur after the first 6 months following stroke (Zhang et al., 2006). Still, there is potential to activate neural plasticity of the visual system after this period by highly specific and timeconsuming training, such as Vision Restoration Training (VRT) or compensatory scanning training (Pollock et al., 2011; Sabel et al., 2011; Kasten et al., 1998; Mueller et al., 2008; Poggel et al., 2004). Additionally, there is scientific evidence in animal and human studies showing neuroplastic effects of repetitive transorbital alternating current stimulation (rTACS) in the visual system after prechiasmatic optic nerve or retinal damage in terms of regaining neurophysiological as well behavioral functionality (Sergeeva et al., 2015; Fedorov et al., 2011, Gall et al., 2011, Sabel et al., 2011). "
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    ABSTRACT: Background & Aims: Although vision loss is a very common and serious complication in cerebral stroke patients, there appears to be a mismatch in the number of studies establishing the potential of noninvasive brain stimulation modalities for post stroke vision loss compared to other complications of cerebrovascular accidents. This review aims to describe the current literature on noninvasive brain stimulation (NIBS) techniques in post cerebral stroke vision loss and suggests future considerations in this field. Methods: Three independent reviewers conducted a systematic search in PUBMED database. We included all publications covering vision-loss after cerebral stroke (case reports, RCT, pilot studies). This search yielded six relevant papers that met our criteria. Results: We found two case reports (1 tDCS, 1 TMS), one comparative case study (tDCS), and three randomized, controlled clinical pilot studies (all tDCS). No study applying tACS on stroke related vision loss fit our criteria. Our review shows that very few studies so far investigated non-invasive brain stimulation techniques as a treatment option in cerebral stroke related vision loss. The case reports as well as the small pilot studies;however, suggest a beneficial effect of applying tDCS over the primary visual cortex in addition to vision restoration training (VRT) in regaining parts of the visual field and accelerating the recovery time. These results are comparable and consistent with findings on stroke related motor and speech rehabilitation with the application of different NIBS protocols. A case report on repetitive TMS (1Hz) showed its potential use in down-regulation of visual cortical areas to cease visual hallucinations as a concomitant in visual field loss, also known as Charles-Bonnet-Syndrome. Conclusion: Although studies are scarce and data are limited, we have found some evidence that NIBS-techniques have positive effects on the rehabilitation of visual field loss post cerebral stroke. More studies are needed to investigate mechanisms of action and proof of efficacy.
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