The document discusses the assessment and treatment of visual perceptual skills and cognitive barriers for patients, particularly focusing on occupational therapy methods used in neuro rehabilitation. It outlines key visual processing concepts, defines various visual perceptual skills, and describes the impact of these impairments on daily functions and tasks. Additionally, it reviews effective interventions for adults with visual and cognitive deficits following brain injuries, emphasizing adaptive and compensatory approaches to enhance performance in everyday activities.

1. FUNCTIONALLY
ASSESSING
& TREATING
Noor Fathimah Bt Mazani (FATHIM)
Occupational Therapist
Hospital Raja Perempuan Zainab II, Kota Bharu Kelantan
✓ Visual Processing
✓ Visual Perception
✓ Visual-motor Deficit

2. 2
3
4
5
1 Terminologies related to the visual perceptual
Relatioship between visual & the brain
The impact on everyday function
Assessment
Intervention
OUTLINES
5
NEURO
REHABILITATION
This slide focus on

3. TERMINOLOGIES
RELATED TO THE VISUAL
PERCEPTUAL

4. ➢ Visual Perception
The brains ability to perceive & interpret the
information that is seen through out eyes
➢ Visual Processing
A term used to refer to the process of perceive &
interprate the information
➢ Visual-motor Deficit
A visual motor deficit refers to a challenge in
coordinating visual perception (what is seen) with
motor skills (physical movements).
VISUAL

5. Visual Perception
The brains ability to perceive & interpret the
information that is seen through out eyes
Visual Processing
A term used to refer to the process of perceive &
interprate the information

6. Visual-motor Deficit
A visual motor deficit refers to a challenge in coordinating visual perception (what is seen)
with motor skills (physical movements).

7. VISUAL PERCEPTUAL SKILLS / FUNCTIONS
VISUAL MEMORY
This one is the ability to retain
information gathered through
visual means. Being able to
obtain the most information
possible in the shortest
amount of time leads to
optimal performance.
VISUAL DISCRIMINATION
This is the ability to be aware of
the distinct features of form,
such as, shape, orientation, size,
and color.
VISUAL SEQUENTIAL
MEMORY
Visual sequential memory is the
capacity to which a person is
able to memorize a series of
objects, such as letters or
words, in the order which they
were first observed.
VISUAL FIGURE GROUND
This skill represents a
person’s capability to
distinguish an object from its
background.
VISUAL SPATIAL SKILLS
These skills are those that are required to understand
directional concepts and organize external visual
information. They are also the skills that govern a
person’s sense of spatial reasoning, and direction in
relation to one’s own body.
VISUAL CLOSURE
Closure in a visual sense
refers to the ability to
recognize a complete
feature from fragmented
information, i.e. being able to
tell what an object is just by
looking at one part of it.
VISUAL FORM
CONSISTENCY
Form Consistency refers to
the ability to recognize
objects as they change in
shape, color, or
orientation.
Reference: L. de-Wit, J. Wagemans, in Encyclopedia of Human Behavior (Second Edition), 2012

8. RELATIOSHIP BETWEEN
VISUAL & THE BRAIN

9. VISUAL & THE BRAIN

10. VISUAL & THE BRAIN

11. 2
3
4
1 OCCIPITAL LOBE
FRONTAL LOBE
PARIETA LOBE
TEMPORAL LOBE
✓ Primary visual cortex
✓ Visual association cortex
✓ Analyzing orientation, position, & movement.
✓ Initiation of Smooth Pursuit Movements
✓ Visual Field Loss
✓ Saccades and Attention
✓ Locating objects
✓ Eye movements
✓ Drawing/construction of objects
✓ Neglect
✓ Movement through space
✓ Combines sensory information associated with the recognition &
identification of objects such as people, places, and things.

12. VISUAL HIERARCHY
Warren, 1993
✓ The foundation includes
ocularmotor control, visual fields,
and visual acuity.
✓ These are the basic visual skills
required to take in information
accurately from our visual world.
✓ Unilateral inattention is represented in this
second level, and this deficit would
complicate our ability to properly scan and
attend to incoming visual information.
✓ Decreased visual scanning would present
difficulties in pattern recognition, which
includes
• from constancy
• figure ground perception
• visual closure
• visual organization
• spatial orientation
Warren, M. (1993a). A hierarchical model for evaluation and treatment of visual perceptual dysfunction in adult acquired brain injury, part 1. The American Journal of
Occupational Therapy, 47(1), 42–54. https://doi.org/10.5014/ajot.47.1.42

13. VISUAL HIERARCHY
Warren, 1993
✓ Moreover, the optimal functioning of pattern
recognition skills are necessary for our ability to retain
visual information, also known as visual memory.
✓ The highest skill level of this hierarchy is visuocognition,
in which we are able to integrate visual perceptual
information with other sensory input in order to complete
executive functioning tasks, such as planning, problem
solving, and decision making.
Warren, M. (1993a). A hierarchical model for evaluation and treatment of visual perceptual dysfunction in adult acquired brain injury, part 1. The American Journal of
Occupational Therapy, 47(1), 42–54. https://doi.org/10.5014/ajot.47.1.42

14. Cognitive Deficits, StatPearls, Aayush Dhakal; Bradford D. Bobrin, 2020
COGNITIVE FUNCTION
“the mental action or
process of acquiring
knowledge and
understanding through
thought, experience, and
the senses”
PERCEPTUAL
and COGNITIVE
PERCEPTUAL FUNCTION
“the ability to interpret
or become aware of
something through the
senses”

15. IMPACT OF VISUAL
PERCEPTUAL AND COGNITIVE
BARRIERS ON
EVERYDAY FUNCTION

16. THE IMPACT
of Visual Perceptual & Cognitive Barriers
ADLs IADLs Community
Integration
Communication
Management /
Accessing
Resources
Work / Vocation /
School

17. THE IMPACT
of Visual Perceptual & Cognitive Barriers
ADLs
• Putting makeup on or shaving only one half of the face
• Difficulty locating shampoo amongst several toiletries
• Trouble locating clothing in a drawer
• Difficulty sequencing shower and dressing routine
• Unsafe transfers (depth perception or executive functions)
• Difficulty remembering a change to morning routine (For example, donning an AFO)
• Difficulty resuming routine if interrupted
• Navigating curbs and uneven surfaces in the community
• Vehicle transfers
• Navigating stairs
• Colliding with walls and furniture
• Tripping over rugs and items on the floor
• Determining safe distance for transfers or sitting

18. THE IMPACT
of Visual Perceptual & Cognitive Barriers
IADLs
• Cannot recognize different coins
• Counting cash incorrectly for making payment or change
• Trouble remembering medical appointments / medications
• Cannot accurately read medication labels
• Trouble making decisions in health related emergencies
• Trouble locating items in the store
• Bumping into displays while shopping
• Gets overstimulated in public
• Impulsively buying unneeded items
• Difficulty pouring liquid ingredients
• Unable to identify appropriate utensils for use
• Unsafe with heat surfaces and sharps
• Inability to sequence a recipe
• Poor lines in the lawn while mowing
• Poor home organization
• Difficulty staying on task
• Unsanitary sequencing while cleaning

19. THE IMPACT
of Visual Perceptual & Cognitive Barriers
Community
Integration
• Unable to identify road signs and pavement markings
• Stopping too soon or too late at intersections
• Unable to plan complex intersections
• Difficulty managing a bus route
• Requires assistance to schedule rides with transportation service
• Difficulty attending to navigation system while driving
• Only scanning one side of the environment and missing signs on the left side
• Poor lane management and speed control

20. THE IMPACT
of Visual Perceptual & Cognitive Barriers
Communication
Management /
Accessing
Resources
• Difficulty scanning for information on phone book pages or websites
• Unable to identify appropriate search terms to locate information
• Cannot remember contact information for personal needs
• Unable to attend to a phone conversation and take notes
• Difficulty sequencing apps on your phone
• Decreased ability to identify the most appropriate professional to contact for
person needs

21. THE IMPACT
of Visual Perceptual & Cognitive Barriers
Work / Vocation /
School
• Difficulty with alternating between projects, phone calls, e-mails, etc.
• Difficulty learning a new job task or role
• Unable to scan for and identify jobsite hazards
• Increased headaches from visual stimulation and lighting
• Difficulty reading small print text
• Cannot maintain organization of work space or school supplies/homework
• Decreased developmental progression of visual perceptual and cognitive
processes impacting school performance
• Increased visual strain with screen time requirements
• Decreased ability to sequence and prioritize tasks
• Unable to multitask and retain information from meetings or conference calls

22. ASSESSMENT

23. Visual Ability
ASSESSMENT
oculomotor control
✓ Saccade
Visual filed
✓ Confrontation
✓ Perimetry test
Visual Acuity
✓ Snellen Test 20/20

24. ✓ Baking Tray Test
✓ Comb & Razor Test
✓ Clock Drawing Test (CDT)
✓ Trail Making A and B
✓ Albert Test
✓ Line Bisection Test
✓ Bell’s Test
✓ Star cancellation
✓ Ogden Scene Drawing Test
✓ Catherine Bergego Scale (CBS)
QUESTIONAIRE
PEN & PAPER TEST
FUNCTIONAL ACTIVITIES
Hemispatial Neglect
ASSESSMENT
Reference: Stroke Engine

25. Standardized Assessment - Manual & Tools
ASSESSMENT
✓ Motor Free Visual Perception Test (MVPT-4)
Subtests for Visual Discrimination, Visual Figure Ground, Visual Memory,
Visual Closure & Visual Spatial
✓ The Occupational Therapy Adult Perceptual Screening
Test (OT-APST)
Screen for Agnosia, unilateral neglect, body scheme, constructional skills,
acalculia & apraxia scales
✓ Loewestein Occupational Therapy Cognitive
Assessment (LOTCA)
Subtests for Orientation, Perception, Visuomotor organization, thinking
operation
Reference: Stroke Engine

26. Standardized Assessment - Manual & Tools
ASSESSMENT
✓ Ontario Society of Occupational
Therapists (OSOT) Perceptual
Evaluation
✓ Visual Impairment Screening
Assessment (VISA)
Reference: Stroke Engine

27. Standardized Assessment - Manual & Tools
ASSESSMENT
✓ Test of Visual Perceptual Skills (TVPS-4)
Subtests for Visual Discrimination, Visual Figure Ground, Visual
Memory, Visual Closure, Visual Spatial Relationship, Visual
Form-Constancy & Visual Sequential Memory
✓ Developmental Test of Visual Perception
Adolescent and Adult (DTVP-A) (DTVP-2)
Visual Motor Search, Visual Motor Speed, Copying, Figure
Ground, Visual Closure & Form Constancy

28. Standardized Assessment - Manual & Tools
ASSESSMENT
✓ Rivermead Perceptual Assessment
Battery (RPAB)
✓ Loewestein Occupational Therapy
Cognitive Assessment (LOTCA) / LOTCA-G
/ D-LOTCA / DOTCA
✓ Chessington OT Neurological Assessment
Battery (COTNAB)

29. ASSESSMENT
✓ Test of Memory and Learning (TOMAL-2)
Abstract visual, sequential, linguistic, numeric, memory for
location, object recall, facial memory etc
✓ Test of Everyday Attention (TEA) / TEA-Ch
Map search, elevator counting, visual elevator, telephone search,
lottery
✓ Symbol Digit Modalities Test (SDMT)
Verbal and visual feedback
Standardized Assessment - Manual & Tools

30. INTERVENTON

31. Strong evidence supports the use of scanning, limited evidence supports the use of
adaptive strategies, and mixed evidence supports the use of cognitive interventions to
improve occupational performance for adults with TBI. Evidence related to vision
therapy varies on the basis of the specific intervention implemented.
Sue Berger et al. 2016
The American Journal of
Occupational Therapy, 2016,
Vol. 70(3), 7003180010p1–
7003180010p7.
Effectiveness of Interventions to Address Visual and Visual–Perceptual Impairments
to Improve Occupational Performance in Adults With Traumatic Brain Injury:
A Systematic Review
Medline, PsycINFO, CINAHL, OTseeker, and the Cochrane Database of Systematic Reviews
were searched, and 66 full text articles were reviewed. Sixteen articles were included in the
review.

32. Glen Gillen et al. 2016
The American Journal of
Occupational Therapy, 2015,
Vol. 69(1), 6901180040p1–
6901180040p9.
Effectiveness of Interventions to Improve Occupational Performance of People With
Cognitive Impairments After Stroke:
An Evidence-Based Review
Forty-six articles met the inclusion criteria and were examined. Interventions for the following
impairments were reviewed: general cognitive deficits, executive dysfunction, apraxia, memory
loss, attention deficits, visual field deficits (included because of their close relationship with
neglect), and unilateral neglect.
There is insufficient evidence regarding impairments of attention and mixed evidence
regarding interventions for visual field deficits. The effective interventions have some
commonalities, including being performance focused, involving strategy training, and
using a compensatory as opposed to a remediation approach.

33. Hanna et al. 2017
wileyonlinelibrary.com/jounal/brb3
Brain and Behavior
The treatment methods for post-stroke visual impairment:
A systematic review
Forty-nine articles (4142 subjects) were included in the review, including an
overview of four Cochrane systematic reviews. Interventions appraised
included those for visual field loss, ocular motility deficits, reduced central
vision, and visual perceptual deficits.

34. Hanna et al. 2017. The treatment methods for post-stroke visual impairment:
A systematic review. wileyonlinelibrary.com/jounal/brb3.Brain and Behavior
Pharmacological &
Surgical
Prisms & Glasses Conventional OT Compensatory
No. of Articles 3 3 2 1
0
0.5
1
1.5
2
2.5
3
3.5
Treatment of
OCULAR MOTILITY DEFECTS

35. Compensatory Substitutive Restitutive Various
No. of
Articles
18 6 17 6
0
2
4
6
8
10
12
14
16
18
20
Treatment of
VISUAL FIELD DEFECTS
Hanna et al. 2017. The treatment methods for post-stroke visual impairment:
A systematic review. wileyonlinelibrary.com/jounal/brb3.Brain and Behavior
✓Computer based training
✓Cognitive skill remediation
✓Neurovisual therapy
✓Visual scanning / search
/ exploration
✓Prisms
✓Gottlieb visual field
awareness system
✓Visual restoration
treatment (VRT)
✓VRT & additional with tDCS
✓Compensatory
✓Substitutive
✓Restitutive

36. Eye Patch
Visual
Scanning
Mental
Practice
Prisms /
Glasses
Trunk
rotation
OKS
Limb
activation
Electrical
Somato
sensory
Stimulation
Computer Various
No. of Articles 5 13 2 4 2 3 2 2 1 3
0
2
4
6
8
10
12
14
Treatment of
VISUAL NEGLECT
Hanna et al. 2017. The treatment methods for post-stroke visual impairment:
A systematic review. wileyonlinelibrary.com/jounal/brb3.Brain and Behavior

37. Reference: Azouvi P, Jacquin-Courtois S, Luauté J. Rehabilitation of unilateral neglect: Evidence-based
medicine. Annals of Physical and Rehabilitation Medicine. 2017;60(3):191-197.
Top-Down Approach
➢ Involve the use of behavioral training to induce cognitive
changes that counteract neglect.
➢ Most commonly, they involve training the patient to scan
towards the neglected side
✓ visual scanning
✓ visual exploration
46%
36%
18%
APPROACHES
Top -down Bottom-up Mixed
Bottom-Up Approach
➢ Attempt to induce a contralesional orientation bias to
counteract the pathologic ipsilesional orientation bias of
visual neglect without relying on patient volition.
➢ Most commonly studied bottom-up techniques include
✓ prism adaptation
✓ optokinetic stimulation
✓ vestibular stimulation
✓ neck-muscle vibration.
The treatment methods for post-stroke visual impairment:
A systematic review

38. VISUAL HIERARCHY
Warren, M. (1993a). A hierarchical model for evaluation and treatment of visual perceptual dysfunction in adult acquired brain injury, part 1. The American Journal of
Occupational Therapy, 47(1), 42–54. https://doi.org/10.5014/ajot.47.1.42
Warren, 1993

39. Adaptive Approach
Remedial Approach
Transfer of training; practice in a particular
perceptual task carries over to performance of
similar activities or task requiring the same
perceptual skills.
Pendleton et al. 2006. Pedretti’s Occupational Therapy: Practice Skills for Physical Dysfunction. 6th Edition
Adaptive / compensatory / functional approach
are characterized by the repetitive practice of
particular tasks that help the person become
more independent in areas of occupation

40. ❑ Compensation is a treatment approach that aims to
maximize existing visual function by providing
strategies to enhance the patient's ability to assimilate
visual information efficiently.
❑ A compensatory approach should also place emphasis
on understanding underlying difficulties in visual
perception in order to learn when to initiate the use of
strategies to overcome limitations.
❑ Rather than focusing on one task specific skill, the
client should gain the ability to use the learned
strategies in various situations.
❑ The practicing strategies for visual perceptual deficits
within context to ensure carryover of application to
ADLs.
Adaptive /
Compensatory
Approach

41. COMPENSATORY
INTERVENTION
TECHNIQUES
PATTERN RECOGNITION
✓ Reducing overlapping
objects
✓ Changing spatial
arrangements into
categorized or linear arrays
✓ Slowing down processing
times
✓ Forming proper scanning
patterns
✓ Multi-sensory techniques
UNILATERAL INATTENTION
✓ Prisms
✓ Attention training
✓ Scrolling text
✓ Audiovisual stimulation
✓ Video feedback training
✓ Learn new scanning patterns
✓ Lighthouse scanning
DEPTH PERCEPTION
✓ Monocular Cues
• Shadowing
• Lines of parallax
• Superimposition
✓ Prisms
COGNITION
✓ Reduce stimulation
✓ Rest breaks
✓ Slowing down
✓ Repetition!
✓ Multi-sensory techniques
✓ Verbalization
✓ Chunking/grouping
✓ Association
✓ “W” Questions
✓ Pro and con lists
✓ STOP strategy
✓ Double checking
✓ Pre-planning

42. ❑ The remedial is typically initiated based on the premise that
the brain can acquire or reacquire function through
environmental stimulation.
❑ Reacquisition of skills should follow the original path of
development.
▪ In Piaget’s model of cognitive development, the lower
level performance components are acquired prior to
more advanced cognitive skills.
▪ Treatment activities should place initial emphasis on
foundational skills, regardless of the individual’s level
of functioning, in order to ensure that the foundation is
solid prior to advancing to higher level cognitive skills.
❑ Choosing activities that have multiple levels of difficulty, the
ability to alter speed requirements, and offer the
opportunity to adjust levels of attention complexity are
important to consider for grading activities up or down to
foster meeting the client’s goals while considering his or
her just right challenge.
Remedial
Approach

43. VISUAL
Normal visual field
90’ Temporally to central
fixation
50’ Superiorly & Nasally
60’ Inferiorly
INTERVENTION’S STRATEGY

44. 1
2
3
Personal space
Peripersonal space
Extrapersonal space
✓ Table task activities
✓ A4 --> A1
✓ White board
✓ Room
INTERVENTION’S STRATEGY

45. 2
3
4
5
1 Captain’s Log ~ Software
CogniPlus ~ Software
dob ~ Software
Durham Reading & Exploration
(DREX) Training
HIGH
INTERVENTION
TECHNOLOGY
3 CogniFit ~ Software
6 Online Games

46. 1 Captain’s Log ~ Software

47. 2
3
4
1 CogniFit ~ Trial version
Durham Reading &
Exploration (DREX) Training
HIGH
INTERVENTION
TECHNOLOGY
3 Free Online Games
FREE ✓ www.cokogames.com
✓ www.tinytap.com
✓ www.theottoolbox.com
✓ www.improvememory.org
✓ www.myhomeschoolmath.com
✓ www.poki.com

48. 2
3
4
5
1 www.pinterest.com
www.chicagooccupationaltherapy.com
www.twinkl.my
www.tuktukdesign.com
WORKSHEET
INTERVENTION 3 www.jet.org.za / JET Education services
6 www.abbythepup.com
7 www.15worksheets.com

51. THANK YOU
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