Effectiveness of Interventions to Address Visual and
VisualPerceptual Impairments to Improve Occupational
Performance in Adults With Traumatic Brain Injury:
A Systematic Review
MeSH TERMS
 brain injuries
 cognitive therapy
 occupational therapy
 photic stimulation
 vision disorders
 visual perception
Sue Berger, PhD, OTR/L, BCG, FAOTA, is Clinical
Associate Professor, Department of Occupational Therapy,
Boston University, College of Health and Rehabilitation
Sciences: Sargent College, Boston, MA; sueb@bu.edu
Jennifer Kaldenberg, MSA, OTR/L, SCLV, FAOTA,
is Clinical Assistant Professor and Academic Fieldwork
Coordinator, Department of Occupational Therapy, Boston
University, College of Health and Rehabilitation Sciences:
Sargent College, Boston, MA.
Romeissa Selmane, MS, OTR/L, is Occupational
Therapist, The Home for Little Wanderers, Boston, MA.
She was Entry-Level Masters Student, Department of
Occupational Therapy, Boston University, College of
Health and Rehabilitation Sciences: Sargent College,
Boston, MA, at the time of this research.
Stephanie Carlo, MS, OTR/L, is Occupational
Therapist, Integrated Childrens Therapy, Miami, FL. She
was Entry-Level Masters Student, Department of
Occupational Therapy, Boston University, College of
Health and Rehabilitation Sciences: Sargent College,
Boston, MA, at the time of this research.
The American Journal of Occupational Therapy
Sue Berger, Jennifer Kaldenberg, Romeissa Selmane, Stephanie Carlo
OBJECTIVE. Visual and visualperceptual impairments occur frequently with traumatic brain injury (TBI)
and influence occupational performance. This systematic review examined the effectiveness of interventions
within the scope of occupational therapy to improve occupational performance for adults with visual and
visualperceptual impairments as a result of TBI.
METHOD. 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.
RESULTS. Strong evidence supports the use of scanning, limited evidence supports the use of adaptive strat-
egies, 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.
CONCLUSION. Although the strength of the research varied, implications are discussed for practice,
education, and research.
Berger, S., Kaldenberg, J., Selmane, R., & Carlo, S. (2016). Effectiveness of interventions to address visual and visual
perceptual impairments to improve occupational performance in adults with traumatic brain injury: A systematic
review. American Journal of Occupational Therapy, 70, 7003180010. http://dx.doi.org/10.5014/ajot.2016.020875
V isual and visualperceptual impairments associated with traumatic brain in-
jury (TBI) are prevalent, with estimates as high as 90% (Jacobson & Marcus,
2011). Physical trauma can damage the visual system, leading to deficits in visual
field, visual acuity, oculomotor skills, and visual processing abilities (Cockerham
et al., 2009). These deficits can affect a persons participation in meaningful
activities (Greenwald, Kapoor, & Singh, 2012; Warren, 2013).
The objective of this systematic review was threefold: (1) to update in-
formation included in the Occupational Therapy Practice Guidelines for Adults
With Traumatic Brain Injury (Golisz, 2009) related to interventions that ad-
dress visual and visualperceptual functions, (2) to synthesize the literature on
interventions within the scope of occupational therapy practice that are effective
in improving occupational performance for adults with visual and visualper-
ceptual impairments as a result of TBI, and (3) to guide the direction of future
research that focuses on interventions to address visual and visualperceptual
challenges in people with TBI. The current review answers the question What is
the evidence that interventions to address visual and visualperceptual impair-
ments and skills improve occupational performance for people with TBI?
Background
Vision includes three basic functions: visual acuity, visual field, and oculomotor
control (Warren, 2013). In this systematic review, visual perception is considered
7003180010p1
an aspect of cognition and is defined as an active pro-
cessing of visual input that interacts with higher level
processing to enable one to interpret the environment
(Bowen, Knapp, Gillespie, Nicolson, & Vail, 2011).
Visual and visualperceptual deficits can significantly
influence participation in meaningful activities (Greenwald
et al., 2012; Warren, 2013). People with visual impair-
ments may be at increased risk for falls, may be limited in
mobility, may have significant reading deficits, and may
display a higher prevalence of depression (McCarty, Fu,
& Taylor, 2002; West et al., 2002; Zhang et al., 2013).
People with TBI frequently experience visual complica-
tions as a result of their injury, including visual field
deficits (46%), convergence insufficiencies (40%48%), ac-
commodative insufficiencies (31%47%), oculomotor defi-
cits (10%30%), and diplopia (6%9%; Cockerham et al.,
2009; Suchoff et al., 2008). Thirty-one percent of people
with severe TBI were found to have visualperceptual im-
pairments 1 yr postinjury (Kersel, Marsh, Havill, & Sleigh,
2001). A growing body of evidence surrounds veterans with
visual and visualperceptual impairments after service-
related TBI. Of veterans of Operation Iraqi Freedom and
Operation Enduring Freedom, 10%20% were diagnosed
with a TBI, and 50%75% of those reported visual
complaints (Bulson, Jun, & Hayes, 2012; Cockerham
et al., 2009). This systematic review summarizes inter-
ventions that address these vision skills.
Method
This systematic review is one of six reviews of the TBI
literature relevant to occupational therapy conducted
under the auspices of the American Occupational Therapy
Association (AOTA) Evidence-Based Practice (EBP)
Project. The six review questions were based on the earlier
set of reviews that covered the literature from 1986 to
2008 and were updated to reflect present clinical practice.
An advisory board consisting of experts in the field and the
review authors provided feedback on the development of
the questions. This review was carried out through an
academic partnership that consisted of two occupational
therapy faculty and two occupational therapy graduate
students. The methods for the reviews were specified in
advance and documented in a protocol for the authors.
Search Strategy
The inclusion criteria for this review were as follows:
Studies were published in peer-reviewed scientific litera-
ture between 2001 and 2013, at least 1 participant in each
study sample was an adult with TBI, articles were written
in English, and interventions were within the scope of
7003180010p2
practice of occupational therapy. The original criteria
specified that at least 50% of participants in each study
have TBI, but we identified only 6 such studies that
addressed the review question. Many studies related to
vision and brain injury exclude people with TBI because of
the multiple challenges accompanying TBI, including
impaired cognition. The pathology of visual or visual
perceptual impairment, however, can be similar in people
with TBI and those with stroke (Ciuffreda et al., 2007).
Therefore, we expanded the search to include relevant
studies that focused on people with stroke but also in-
cluded at least 1 participant with TBI.
Additionally, the previous review of the literature
related to occupational therapy interventions and TBI
(Golisz, 2009) did not address the complex visual issues
associated with TBI but rather addressed vision as a
component of cognition and focused on visual attention
and visual cognitive skills. Therefore, we expanded the
search dates to 2001 or later to include studies specifically
related to vision and visual perception that were not
included in the most recent Occupational Therapy Prac-
tice Guidelines for Adults With Traumatic Brain Injury
(Golisz, 2009).
The authors discussed several topics, including apraxia,
spatial neglect, facial recognition, and emotion processing, to
determine whether they should be considered within the
domain of the vision and visual perception review question.
After discussion with content experts and AOTA liaisons,
we determined that apraxia and spatial neglect would be
included in the review addressing cognition, and facial
recognition and emotion processing, types of perceptual
disorders, would be included in this review.
Using the evidence hierarchy described by Sackett,
Rosenberg, Muir Gray, Haynes, and Richardson (1996),
descriptive outcome studies such as single-subject and
case series designs (Level IV evidence) and case reports,
narrative literature reviews, and consensus statements
(Level V evidence) were included only when Level I
(systematic reviews, meta-analyses, randomized controlled
trials [RCTs]), Level II (two-group nonrandomized
studies), or Level III (one-group nonrandomized
studies) evidence was not found. The reviews excluded
qualitative studies and reports from presentations, con-
ference proceedings, nonpeer-reviewed research literature,
dissertations, and theses.
The EBP methodology consultant to the AOTA EBP
Project and AOTA staff identified search terms in con-
sultation with the review authors and the advisory group.
The final terms were selected on the basis of the specific
thesaurus included in each database. A medical research
librarian with experience in completing systematic review
May/June 2016, Volume 70, Number 3
searches further refined the search strategies and conducted
all searches. The databases and sites that were searched
included Medline, PsycINFO, CINAHL, OTseeker, and
the Cochrane Database of Systematic Reviews. The review
teams examined reference lists from articles that were
identified for inclusion for additional potential articles,
and selected journals were hand searched to ensure that all
appropriate articles were included. See Supplemental Ap-
pendix 1 (available online at http://otjournal.net; navigate
to this article, and click on Supplemental) for one of the
electronic search strategies for this question.
Study Selection, Data Extraction, and Risk of
Bias Assessment
The EBP Project methodology consultant first eliminated
references for each question on the basis of citations and
abstracts. As the review team, we also reviewed these ci-
tations and abstracts and eliminated additional references.
We then retrieved the full-text versions of the articles for
the remaining references and reviewed them for relevance
to the question, study quality, and levels of evidence. Each
included article was abstracted using an evidence table that
included the level of evidence, a summary of the study
methods, and findings relevant to the review question.
AOTA staff and the EBP Project consultant reviewed the
evidence tables to ensure quality control before we un-
dertook a more in-depth review and summarization.
We assessed the risk of bias of individual studies using
the methods described by Higgins, Altman, and Sterne
(2011) and of systematic reviews using the measurement
tool developed by Shea et al. (2007). Two team members
reviewed each article separately to complete the evidence
table and determine risk of bias. Whenever there was a
difference in opinion, the reviewers discussed their rea-
soning, and when needed, a third person reviewed the
article as well. Risk of bias was considered in determining
the strength of evidence for each study.
Data Synthesis Methods
Given the heterogeneity of the included studies, we used a
qualitative approach to data synthesis. We examined the
studies selected for review for similarities across partici-
pants, settings, interventions, and outcomes and grouped
related studies into themes.
Designations of the strength of the evidence for each
theme were adapted from the system proposed by the
Agency for Healthcare Research and Quality, U.S. Pre-
ventive Services Task Force (2012). The designation of
strong evidence indicates consistent results from well-
conducted studies, usually at least 2 RCTs. A designation
of moderate evidence was made on the basis of 1 RCT or 2
The American Journal of Occupational Therapy
or more studies with lower levels of evidence. The desig-
nation of limited evidence was based on few studies with
low levels of evidence. A designation of mixed evidence
indicates that the findings were inconsistent across studies
in a given category. Finally, a designation of insufficient
evidence was used when the number and quality of studies
were too limited to make any clear classification.
Results
A total of 584 potential abstracts were screened during the
original search, of which 66 were selected for full article
review (Figure 1). Sixteen articles met the criteria and
were included in the review. Sample sizes ranged from
3 to 40, of which the number of participants with TBI
ranged from 1 to 39. Supplemental Table 1 (available
online) summarizes the study characteristics, participant
characteristics, interventions, and results described in the
included articles.
Most of the studies had low attrition and reporting
bias, but because the majority (9 of 14) were not RCTs,
they had relatively high selection bias (Supplemental Table
2, available online). The 2 included systematic reviews had
relatively low risk of bias (Supplemental Table 3, also
available online).
Visual Scanning
Visual scanning refers to the eye movements used to locate
and identify an object. Strong evidence from 2 Level I
systematic reviews and 1 Level I RCT indicates that scan-
ning is an effective intervention to improve search skills
when measured with computer search tests (Bouwmeester,
Heutink, & Lucas, 2007; Cicerone et al., 2011) and a
functional search task (Roth et al., 2009). Insufficient evi-
dence, based on 1 Level I RCT and 1 Level II study,
supports scanning as a stand-alone intervention to improve
reading (Lane, Smith, Ellison, & Schenk, 2010, Level II;
Roth et al., 2009, Level I). The multifactorial nature of
reading may require additional skill training (e.g., training
with small saccades and directionality in addition to scan-
ning training). All the studies focused on scanning training
through structured computer programs.
Adaptive Strategies
Prisms and scrolling text are adaptive strategies. The pre-
scription of prisms can be used with people with hemi-
anopsia to enhance their awareness of the impaired visual
field by shifting an image from the nonseeing area into the
seeing area. Scrolling text is a computer-based strategy in
which the person maintains focus centrally while the text
moves right to left. Limited evidence from 1 Level III study
7003180010p3
Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram of published literature search.
Figure format adapted from Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement, by D. Moher, A. Liberati, J. Tetzlaff, &
D, G, Altman; PRISMA Group, 2009, British Medical Journal, 339, b2535. Used under the terms of the Creative Commons Attribution License.

supports the use of Fresnel 40-diopter prisms to improve
visual field awareness and functional mobility (Giorgi,
Woods, & Peli, 2009). Self-reported improvements were
noted in perceived quality of life, visual field awareness,
walking, negotiation in crowds, and obstacle avoidance.
Limited evidence from 1 Level II study supports the use
of scrolling text to improve reading performance for
people with reading difficulties resulting from hemianopsia
(Spitzyna et al., 2007). Spitzyna and colleagues found that
scrolling text right to left improved reading saccades and
reading speed after 4 wk of daily sessions.
Vision Therapy
Vision therapy typically refers to a structured form of vi-
sual exercise determined in collaboration with an eye care
specialist.
Vision Therapy for Oculomotor Dysfunction. Limited
evidence from 1 Level II study and 1 Level III study
supports the use of vision therapy to remediate oculomotor
signs and symptoms in people with TBI (Alvarez et al.,
2010, Level II; Ciuffreda et al., 2008, Level III). Evidence
to support the use of vision therapy as a means to facilitate
change in cortical activity, as measured by functional MRI,
in relation to visual function is insufficient (Alvarez et al.,
2010, Level II).
Vision Therapy for Visual Field Deficits. Visual restorative
therapies (VRTs), a subset of vision therapy, are remedial
interventions that attempt to stimulate the impaired visual
field by introducing lights, letters, or objects randomly
outside the intact field of view. Evidence to support the
use of VRTs to improve visual search skills is insufficient
(Roth et al., 2009, Level I). The evidence is also in-
sufficient to support using VRTs to improve visual field
deficits (Bouwmeester et al., 2007, Level I systematic
review; Cicerone et al., 2011, Level I systematic review;
Roth et al., 2009, Level I RCT). A Level I systematic
review reported that available studies had too many
critical limitations to make any definitive recommenda-
tions (Bouwmeester et al., 2007), whereas another found
some subjective evidence of improvement with VRTs for
reading and visual function (Cicerone et al., 2011).
Audiovisual Stimulation for Visual Field Deficits or
Oculomotor Symptoms. Audiovisual stimulation (AVT)
consists of scanning training in which a visual stimulus,
typically illumination of light-emitting diodes, is pre-
sented accompanied by a white noise auditory stimulus.
Moderate evidence from 1 Level I RCT and 2 Level II
studies supports AVT as being more effective in im-
proving visual exploration and reading performance in
people with visual field deficits or oculomotor symptoms

7003180010p4 May/June 2016, Volume 70, Number 3

than VRT without auditory stimulus (Ciuffreda, Han,
Kapoor, & Ficarra, 2006, Level II; Keller & Lefin-Rank,
2010, Level I; Passamonti, Bertini, & Ladavas, 2009,
Level II). Limited evidence from 1 Level II study indi-
cates that the improvements with AVT were long lasting,
with results maintained 1 yr after the end of training
(Passamonti et al., 2009). Limited evidence from 1 Level I
RCT supports the use of AVT to improve performance of
activities of daily living (Keller & Lefin-Rank, 2010).
Cognitive Interventions
Cognitive retraining strategies include graduated practice
of increasingly complex tasks, a focus on increasing at-
tention to contextual cues, errorless learning, self-talk,
pacing, social skills training, and home practice. Strong
evidence from 2 Level I RCTs and 2 Level II studies
indicates that participation in cognitive rehabilitation can
improve participants performance in neuropsychological
measures focused on visual perception (Bornhofen &
Mcdonald, 2008, Level I; Laatsch & Krisky, 2006, Level
II; Powell, Letson, Davidoff, Valentine, & Greenwood,
2008, Level II; Radice-Neumann, Zupan, Tomita, &
Willer, 2009, Level I). Insufficient evidence based on 1
Level I RCT supports the use of cognitive strategies fo-
cusing on social skills training to improve the ability to
name basic emotions, interpret comments, and determine
whether a person is lying or being sarcastic (McDonald
et al., 2008).
Discussion
Overall, the literature addressing interventions within the
scope of occupational therapy practice for people with
visual and visualperceptual deficits from a TBI is lim-
ited. The studies reviewed provide strong evidence to
support the use of scanning as a compensatory strategy to
improve computer visual search skills in people with vi-
sual field deficits but limited evidence of functional im-
provements after intervention (Bouwmeester et al., 2007;
Cicerone et al., 2011; Lane et al., 2010; Roth et al., 2009).
Moderate evidence supports audiovisual stimulation for
people with visual field deficits or oculomotor symptoms
(Alvarez et al., 2010; Ciuffreda et al., 2006, 2008; Keller
& Lefin-Rank, 2010; Passamonti et al., 2009). Research
supporting the use of prisms and scrolling text for people
with impaired visual field is limited (Giorgi et al., 2009;
Spitzyna et al., 2007). Finally, strong evidence supports
the use of a cognitive retraining approach for people with
visualperceptual deficits in improving test scores, but
there is insufficient evidence that these test improvements
generalize to function (Bornhofen & Mcdonald, 2008;
The American Journal of Occupational Therapy
Laatsch & Krisky, 2006; Powell et al., 2008; Radice-
Neumann et al., 2009).
Limitations present in many of the studies in this
systematic review include small samples, lack of control for
unilateral inattention, outcomes that were not functional,
interventions that might be considered outside of the
scope of occupational therapy practice, and lack of control
for other therapies participants received during the study.
Variability in participant characteristics across studies
(e.g., severity of injury, length of time since injury) may
limit the generalizability of the interventions. It is worth
noting that it can be difficult to recruit large numbers of
people with TBI with visual or visualperceptual im-
pairment, and therefore many studies did not include a
control group but instead used a within-subjects design.
Given the potential for selection, performance, and de-
tection bias in several studies, we considered these chal-
lenges in the results of this systematic review.
Implications for Occupational Therapy Research
Occupational therapy practitioners often use interventions
to address the myriad of visual deficits associated with TBI
that have been found to be effective with other pop-
ulations, such as people with stroke or low vision di-
agnoses, but that have not been studied in people with TBI
(e.g., optical devices, compensatory strategies; Kaldenberg
& Smallfield, 2013; Niemeier, Cifu, & Kishore, 2001).
People with TBI present with multiple challenges beyond
impaired vision, including cognitive and motor limita-
tions. These additional limitations might influence the
effectiveness of interventions typically used with other
populations.
More research is needed regarding interventions that
include occupational performance outcomes for people
with vision and visualperceptual impairments from TBI.
More studies are needed that use rigorous research de-
signs, include larger sample sizes, explore dosage of in-
tervention, and determine characteristics of clients most
likely to benefit from specific interventions.
Implications for Occupational Therapy Education
Academic curricula should provide coursework addressing
the unique needs of adults with visual impairments as a
result of TBI, providing opportunities to practice the
interventions that have been found effective for this
population, and discussing the limitations in the available
evidence. In addition, providing continuing education to
occupational therapy practitioners working with adults
who have visual deficits as a result of TBI can promote
evidence-based practice and advance current practice.
7003180010p5
Implications for Occupational Therapy Practice
Occupational therapy practitioners working with adults
with TBI must understand the implications of visual and
visualperceptual deficits for occupational performance
and choose interventions based on their reasoning and
available evidence. Preliminary support is available for the
following interventions to address vision and visual per-
ception in people with TBI:
Scanning training for people with impaired visual field
Audiovisual stimulation for people with impaired vi-
sual field or oculomotor symptoms
Adaptive strategies such as prisms and scrolling text for
people with impaired visual field
Application of a cognitive retraining approach for peo-
ple with visualperceptual impairments.
Occupational therapy practitioners should always use
these techniques in conjunction with occupations to
support carryover of improved vision and visual percep-
tion to daily activities. In addition, practitioners should
review the evidence related to stroke and low vision and
use clinical reasoning to determine whether any of the
strategies used for other populations might be appropriate
for clients with TBI. s
Acknowledgments
We thank Deborah Lieberman and Marian Arbesman for
their support and guidance in the methodology of this
review and Janet Powell for her helpful feedback on initial
drafts of this article.
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 Supplemental Table 1. Evidence for the Effectiveness of Interventions to Improve Vision and VisualPerceptual Impairments and Skills of People With Traumatic Brain Injury
Author/Year Level/Design/Participants
Alvarez et al. (2010) Level II
2 groups, nonrandomized
N 5 17
Intervention group, n 5 4 women
with convergence insufficiency
(2 with mild TBI, 2 with no history of
brain injury; M age 5 23); none had
participated in vision therapy
before study.
Control group, n 5 13 adults with no
vision loss (9 men, 4 women;
M age 5 25).
Bornhofen & Mcdonald Level I
(2008)
RCT with wait list
N 5 11 adults with severe TBI and
deficits in emotion processing.
Intervention group, n 5 5 (M age 5
29.2).
Wait list group, n 5 6 (M age = 43.5).
The American Journal of Occupational Therapy, May/June 2016, Volume 70, Number 3
Bouwmeester, Heutink, & Level I
Lucas (2007)
Systematic review
N 5 14 studies (2 RCTs and 12 RMDs;
2 RCTs and 5 RMDs describing
effects of VRT, 7 RMDs describing
effects of scanning compensatory
therapy).
Participants: People with HVFDs after
postchiasmatic lesion
Databases searched: MEDLINE, Embase,
CINAHL, and the Cochrane Central
Registers of Controlled Trials for articles
published 19662005/2007 in English,
German, or Dutch
1
Intervention
Intervention group: Home-based vision therapy
consisting of use of Brock string and loose stick
prism (alternating morning and evening) followed
by clinic-based therapy consisting of step and
ramp stimuli (18 hr total, 6 at home and 12 at
clinic)
Control group: Same as intervention group
Intervention condition: Graduated practice of
increasingly complex tasks of judging emotions
on the basis of context, static visual cues
(photographs), dynamic visual cues (video
vignettes), and situational cues in groups of
23 with 1 therapist; intervention included
group activities, notebook maintenance, and
home practice tasks (1.5-hr sessions 2/wk
over 8 wk)
Control condition: Wait list
Visual search strategies or VRT
Outcome Measures Results
Stereopsis Results were analyzed between groups and also
NPC break value for the intervention group over time.
RPC
Near fusional vergence NPC and RPC decreased significantly for
Dissociated near phoria intervention participants after therapy, and
positional functional vergence at near
CISS
Dynamic eye movement increased.
Neural correlate measurements 3 of the 4 participants were considered
improved or successful on the basis of specific
outcome criteria for clinical significance
measures based on the CISS.
Facial expression naming task Significant gains were noted in two areas: (1)
Facial expression matching task judging dynamic cues related to basic emotions
Awareness of Social Inference Test Parts and (2) judging situational cues and determining
1, 2, and 3 whether the person was lying or being sarcastic or
Sydney Psychosocial Reintegration Scale sincere.
No significant gains were made in judging static
cues.
Visual field size No evidence was found that restoration is
Visual search field better than compensation. For now, visual
Reading time and error search is recommended because it is simpler
Visual scanning and more user friendly and may provide more
Subjective measures and questionnaires successful results (or at least as successful
as VRT).
(Continued)
 Supplemental Table 1. Evidence for the Effectiveness of Interventions to Improve Vision and VisualPerceptual Impairments and Skills of People With Traumatic Brain Injury (cont. )
Author/Year Level/Design/Participants
Cicerone et al. (2011) Level I
Systematic review
N 5 112 studies related to vision
(5 Level III).
Participants: Primarily adults with stroke
or TBI
Databases: PubMed, Infotrieve
Ciuffreda, Han, Kapoor, & Level II
Ficarra (2006)
Crossover experimental
N 5 14 adults (9 with mild TBI, 5 with
stroke) assigned to training method in
counterbalanced manner, separately for
those with TBI and those with stroke
(9 men, 5 women; M age 5 48.4).
Ciuffreda et al. (2008) Level III
Retrospective study
N 5 40, 33 with TBI, 7 with stroke (M age
of those with TBI 5 42.3 [3 age 11, all
others age 18]).
The American Journal of Occupational Therapy, May/June 2016, Volume 70, Number 3
Giorgi, Woods, & Peli Level III
(2009)
1 group, nonrandomized, beforeafter
N 5 23, 2 with TBI, 16 with stroke, 4 with
brain tumor resection, 1 with congenital
hemianopsia (14 men, 9 women; M
age 5 46); 19 completed study.
2
Intervention
VRT to address visual field deficits
Versional oculomotor training using computer-
controlled stimuli (Visagraph) encompassing
fixation, saccade, pursuit, and simulated reading;
at Week 4, oculomotor auditory feedback related
to eye position added or deleted (1 hr 2/wk over
8 wk)
Conventional optometric vision therapy:
vergence, version, and accommodative therapy
Use of a 40-diopter Fresnel Press-On prism in the
superior and inferior position of the glasses
(upper prism placed at Visit 2, lower prism
segment at Visit 3). Participants were directed to
make a vertical head movement so that an object
of interest detected with the prism segment was
viewed through the central portion of the
spectacle lens. At Visit 2, the researcher assessed
peripheral visual field awareness with a
prism-reaching task on the hemianopic side,
then walked the participant through the
environment observing obstacles. The
participant was instructed in 2 brief training tasks
to be performed at home at least 2/day. Visit 3
was similar to Visit 2 but for lower prism
segment. (5 visits over a mean of 9 wk, range 5
513 wk)
Outcome Measures Results
Visual function Some evidence was provided that VRT
Reading speed improved visual function and reading speed.
Findings were inconclusive regarding whether
VRT improved visual field or whether change
was attributable to compensatory strategies as
well (cueing attention). VRT is recommended
as a practice option.
Fixation, saccade, pursuit Significant improvement was noted in objective
Simulated reading and subjective reading, but only in 5
Subjective reading rating scale questionnaire participants; in 4 participants, reading remained
Simulated reading saccade ratio unchanged (improvement was shown in both
Visagraph groups but was greater with combined vision
and auditory). Other outcomes also
demonstrated significant improvement that
remained at 3 mo.
Marked improvement or normalization of at Of the participants with TBI, 30 (90%) showed
least 1 primary symptom (from self-report) complete or marked improvement in 1 or more
and at least 1 primary sign (clinical sign, of their primary symptoms, and 27 (90%)
optometric test) showed improvement or normalization in 1 or
more of their primary clinical signs.
Bells Test 14 participants (67%) chose to continue
Line bisection test wearing the glasses; 5 participants (42%)
Goldmann kinetic perimetry continued to wear the glasses at the long-term
Visual Function Questionnaire follow-up.
Visual field expansion of 22 in the upper and
lower quadrants was seen in all participants.
2 participants had a transient adaptation to the
change in visual directions. Participants
perceived significantly reduced difficulty
noticing obstacles in the hemianopic side, with
the potential to increase quality of life.
(Continued)
 Supplemental Table 1. Evidence for the Effectiveness of Interventions to Improve Vision and VisualPerceptual Impairments and Skills of People With Traumatic Brain Injury (cont. )
Author/Year Level/Design/Participants
Keller & Lefin-Rank Level I
(2010)
RCT, 2 groups, pretestposttest
N 5 20 adults with hemianopsia or
quadrantanopsia, 18 with stroke, 1 with
tumor, 1 with TBI (M age 5 59.15); all
had suffered unilateral lesions of the
occipital lobes 224 wk before
intervention.
Intervention group, n 5 10.
Control group, n 5 10.
Laatsch & Krisky (2006) Level II
Pretestposttest
N 5 6 adults.
Intervention group, n 5 3 with TBI
(M age 5 40).
Control group, n 5 3 (M age 5 35.7).
The American Journal of Occupational Therapy, May/June 2016, Volume 70, Number 3
Lane, Smith, Ellison, & Level II
Schenk (2010)
2 groups, nonrandomized,
pretestposttest
N 5 42, 4 with TBI.
Intervention Group A, n 5 21 (16 men,
5 women; M age 5 65.3).
Intervention Group B, n 5 21 (15 men,
6 women; M age 5 57.1).
3
Intervention
Intervention group: AVT: Participants looked into
the center of an apparatus that delivered visual
stimuli to the blind visual field and intact visual
field in random sequence. Participants had to
detect the presence of visual targets and press a
button as quickly as possible. Study used 20%
catch trials with solely acoustic stimulation;
whenever the participant responded to a catch
trial, a computerized noise sounded. Intervention
occurred in an inpatient rehabilitation setting. (20
30-min sessions over 3 wk)
Control group: Visual stimulation training: Same
intervention, but sound was turned off and catch
trials were not needed.
Intervention group: Cognitive rehabilitation
therapy along with visual scanning, vision
perception, attention, verbal fluency, and reading
on the basis of participants strengths and
weaknesses. Intervention included systematic,
repeated presentation of graded-difficulty
computerized tasks (to address visual processing
deficits) and noncomputerized tasks (to address
visual processing, visual perception, visual
scanning, and reading) and included both clinic
and home tasks. All participants were asked to
read aloud for 2030 min/day and complete word
searches at home. (1-hr weekly cognitive
rehabilitation therapy over 711 mo depending
on participant progress)
Control group: No intervention.
Intervention Group A: Exploration training
Intervention Group B: Attention and exploration
training
Both interventions used software on a laptop
computer that encouraged visual search and took
place in 15 sessions, 288 trials/session (9 tasks
in 32 trials), mean duration of exploration training
5 4 wk at z40 min/session; mean duration of
attention training 5 3.5 wk at z30 min/session.
Outcome Measures
Eye movements (e.g., saccades)
Visual exploration test (computer based)
Reading test (speed)
Search task (objects on board)
ADLs (evaluated by OT): finding objects,
avoiding bumping into objects, eye contact,
seeing obstacles, and reading
Electro-oculography
fMRI
Performance Intelligence Scale
Picture Completion subtest
Visual attention and scanning, Trails A
and B
Digit Vigilance Test
Iowa-Chapman Reading Test
Controlled Oral Word Association Test
Wide Range Achievement Test
Perimetry
Find-the-number visual search
Projected visual search
Visuomotor search
Reading
Visual impairments questionnaire
Results
Significant improvements were noted for AVT
compared with visual training in all measures;
some of the outcomes for vision alone were
significant, but results were always better with
audio and visual combined.
Participants demonstrated significant
improvements on 2 neuropsychological
measures between pre- and posttest indicated
by t scores (1 SD).
Exploration training did not lead to a greater
increase in visual field than attention training.
Exploration training led to significant improvements
in visual search, but attention training did not.
No significant differences in projected visual
search were found between groups; within-
subject attention training was more beneficial
than exploration training.
No significant difference in visuomotor search
was found between exploration training and
attention training.
(Continued)
 Supplemental Table 1. Evidence for the Effectiveness of Interventions to Improve Vision and VisualPerceptual Impairments and Skills of People With Traumatic Brain Injury (cont. )
Author/Year Level/Design/Participants
McDonald et al. (2008) Level I
RCT
N 5 39 people with severe TBI from
Australia >1 yr postinjury.
Intervention group, n 5 13 (10 men,
3 women; M age 5 35.5).
Control Group 1, n 5 13 (8 men,
5 women; M age 5 34.3).
Control Group 2, n 5 13 (10 men,
3 women; M age 5 35.3).
Passamonti, Bertini, & Level II
Ladavas (2009)
Pretestposttest
N 5 24 right-handed adults.
The American Journal of Occupational Therapy, May/June 2016, Volume 70, Number 3
Intervention group, n 5 12 with chronic
hemianopsia, 3 with TBI, 9 with stroke
(9 men, 3 women; M age 5 42.67).
Control group, n 5 12 healthy
participants (M age 5 40).
Powell, Letson, Davidoff, Level II
Valentine, & Greenwood
(2008) Pretestposttest, nonrandomized
controlled (cohort)
N 5 32 adults with brain injury.
Intervention group, n 5 20
(M age 5 40.3).
Control group, n 5 12 (M age 5 46.1).
4
Intervention
Intervention group: Social skills training (social
perception portion used same protocol as in
Bornhofen & Mcdonald, 2008) with gradually
more complex tasks focusing on recognizing
specific features. Speechlanguage pathologists
or psychologists ran each group. Intervention
occurred in hospital outpatient and community
facilities. (3-hr sessions 1/wk over 12 wk.)
Control Group 1: Social activity only (placebo)
Control Group 2: Wait list (deferred)
Intervention group: Control visual training and
subsequent audiovisual training consisting of
visual scanning and visual scanning with auditory
stimulation (4 hr/day over 2 wk)
Control group: No intervention
Intervention group: Training in the following
strategies using 4 sets of 10 photographs of
faces: semantic association, caricaturing, part
recognition, and simple exposure; order was
counterbalanced (4 sessions over 2 wk)
Control group: Simple exposure: Presentation of
a set of faces using the same basic protocol but
with no further elaboration
Outcome Measures
Social perception: Awareness of Social
Inference Test (3 scales tested using
video vignettes: ability to name basic
emotions, ability to interpret comments,
ability to determine whether the person is
lying or not, sarcastic or not)
Social skills assessments
Visual field testing
Triangle test
ADL assessment
Eye movement
Number test
Recognition of target faces measuring
accuracy of recognition at end of training
protocol
Visual processing: Ravens Coloured
Progressive Matrices
Labeling of facial expression
Position Discrimination Test from the
Visual Object and Space Perception
Battery
Unusual Views Test
Letter cancellation
Results
Neither intervention had a significant effect on
reading performance.
Reading was the only item on the visual
impairments questionnaire that showed
significant improvement after exploration
training.
No significant change in social perception was
found.
No improvement in actual restoration of visual
field was found. Improvements were noted in
visual detection and perceptual sensitivity, ADL
performance, visual search, and reading.
No significant change between groups was
found in visual processing (p 5 .06).
A significant change in correlation with
recognition was found after 6 trials of simple
exposure (p < .05).
Semantic association, caricaturing, and part
recognition all significantly enhanced
recognition of faces unfamiliar to participants
before training.
(Continued)
 Supplemental Table 1. Evidence for the Effectiveness of Interventions to Improve Vision and VisualPerceptual Impairments and Skills of People With Traumatic Brain Injury (cont. )
Author/Year Level/Design/Participants Intervention
Radice-Neumann, Zupan, Level I Intervention Group 1: FAR using computer
Tomita, & Willer (2009) program of photos and feedback to address facial
RCT
feature processing (Part 1) and identification of
N 5 19 adults with ABI. own internal emotions (Part 2).
Intervention Group 1, n 5 10 (8 men, Intervention Group 2: SEI using Social Stories on
2 women; M age 5 47). a computer (visual and auditory) relating to
participants own experiences, how they would
Intervention Group 2, n 5 9 (6 men, have felt, and so forth.
3 women; M age 5 38).
All interventions occurred 1:1 in a private room in
a hospital (3/wk for 1 hr over 23 wk; 69 hr total
depending on participants learning capacity)
Outcome Measures Results
Facial affect FAR produced significant improvements in
Vocal affect recognizing facial features, inferring emotions
Emotion evaluation test from context and socioemotional behavior, and
Emotional inference from context transferring learning to daily settings.
Socioemotional behavior (caregiver
questionnaire) SEI produced fewer improvements than FAR;
improvements were found 2 wk posttraining in
participants ability to infer how they would feel
in a specific situation.
Results suggest that people with brain injury
can relearn affect recognition skills.

Roth et al. (2009) Level I
RCT (2 groups)
N 5 30, 24 with hemianopsia, 6 with
quadrantanopsia, 1 with TBI; 2 dropped
out from FT group, so final N 5 28.
Intervention Group 1, n 5 15 (11 men,
4 women; M age 5 60.47).
Intervention Group 1: EST saccadic search task
aimed at improving search in the blind hemifield
using computer software in home setting (30
min/day, 5 days/wk over 6 wk)
Intervention Group 2: FT to improve sensitivity of
the blind hemifield, not to foster exploratory eye
movements, using computer software in home
setting (30 min/day, 5 days/wk over 6 wk)
Digit search task identical to EST practice
but in structured manner with head stable
Natural search task
Eye fixation stability during natural scene
exploration
Perimetry
Reading speed
Vision-related quality of life questionnaire
Differences were found between groups
(favoring EST) for all outcome measures except
reading speed and visual fields (perimetry).
The EST group demonstrated translation to
functional activities, specifically social domain
(e.g., they found it easier to notice people).

Intervention Group 2, n 5 15 (8 men,

7 women; M age 5 60.27).

Spitzyna et al. (2007) Level II Intervention Group 1: Practice in reading moving Eye movement recordings Group 1 showed significant improvements in

The American Journal of Occupational Therapy, May/June 2016, Volume 70, Number 3
2 group, 2-armed crossover
N 5 19 adults with right homonymous
hemianopsia that interfered with reading.
Intervention Group 1, n 5 11 (6 men,
5 women; M age 5 49.73).
Intervention Group 2, n 5 8 (7 men,
1 woman; M age 5 65.13).
text that scrolled from right to left (1/day for 2
4-wk blocks)
Intervention Group 2: Sham therapy (spot the
difference) for the 1st block and then crossover
to moving text for the 2nd (20 sessions of 20 min
over 4 wk)
Reading speed
Visual perimetry
Wechsler Abbreviated Scale of Intelligence
Test of visuospatial function
Visual Object and Space Perception Battery
Graded test of spelling
Warrington Recognition Memory Test for
words and faces
static text reading speed over both therapy
blocks (18% improvement).
Group 2 did not significantly improve over the
first block (5% improvement) but improved
at crossover to the moving text block
(23% improvement).
Moving text therapy was associated with a
significant effect on saccadic amplitude for
rightward but not leftward reading saccades.

Note. ABI 5 acquired brain injury; ADL 5 activity of daily living; AVT 5 audiovisual stimulation training; CISS 5 Convergence Insufficiency Symptom Survey; EST 5 explorative saccade training; FAR 5 facial affect
recognition; fMRI 5 functional MRI; FT 5 flicker stimulation training; HVFD 5 homonymous visual field defects; M 5 mean; NPC 5 near point convergence; OT 5 occupational therapist; RCT 5 randomized controlled trial;
RMD 5 repeated-measures design; RPC 5 recovery point of convergence; SD 5 standard deviation; SEI 5 stories of emotional inference; TBI 5 traumatic brain injury; VRT 5 vision restoration therapy.
This table is a product of AOTAs Evidence-Based Practice Project and the American Journal of Occupational Therapy. Copyright 2016 by the American Occupational Therapy Association. It may be freely reproduced for
personal use in clinical or educational settings as long as the source is cited. All other uses require written permission from the American Occupational Therapy Association. To apply, visit http://www.copyright.com.
Suggested citation: Berger, S., Kaldenberg, J., Selmane, R., & Carlo, S. (2016). Effectiveness of interventions to address visual and visualperceptual impairments to improve occupational performance in adults with traumatic
brain injury: A systematic review (Suppl. Table 1). American Journal of Occupational Therapy, 70, 7003180010. http://dx.doi.org/10.5014/ajot.2016.020875

5
 Supplemental Table 2. Risk of Bias for Studies Included in the Review (Except Systematic Reviews)

Random Sequence
Citation
Alvarez et al. (2010)
Bornhofen & Mcdonald (2008)
Ciuffreda, Han, Kapoor, &
Ficarra (2006)
Ciuffreda et al. (2008)
Giorgi, Woods, & Peli (2009)
Keller & Lefin-Rank (2010)
Laatsh & Krisky (2006)
Lane, Smith, Ellison, &
Schenk (2010)
McDonald et al. (2008)
Passamonti, Bertini, &
Ladavas (2009)
Powell, Letson, Davidoff,
Valentine, & Greenwood (2008)
Radice-Neumann, Zupan,
Tomita, & Willer (2009)
Roth et al. (2009)
Spitzyna et al. (2007)
Note. Categories for risk of bias: 1 5 low risk of bias; ? 5 unclear risk of bias; 5 high risk of bias. NA 5 not applicable.
Selection Bias
Allocation
Generation Concealment
1 1
1 ?
1 1
1 ?
? ?
Patient-Reported Outcomes: Incomplete Outcome Data (Attrition Bias)
Blinding of Participants and Personnel Blinding of Outcome Selective Reporting
(Performance Bias) Assessment (Detection Bias) Short Term (26 wk) Long Term (>6 wk) (Reporting Bias)
1 1 1
1 1 NA 1
? 1 1 NA 1
? ? 1 1 1
1 1 1
1 1 1 NA 1
1 ? 1 NA 1
1 1 1 NA 1
1 1 1 NA 1
1 1 1 1 1
1 1 1 NA 1
1 ? 1 NA 1
1 ? 1 NA 1
1 1 1 1 1

The American Journal of Occupational Therapy, May/June 2016, Volume 70, Number 3
Table format adapted from Assessing Risk of Bias in Included Studies, by J. P. T. Higgins, D. G. Altman, and J. A. C. Sterne, in Cochrane Handbook for Systematic Reviews of Interventions (Version 5.1.0, Chapter 8), by
J. P. T. Higgins and S. Green (Eds.), 2011, London: Cochrane Collaboration. Retrieved from http://www.cochrane-handbook.org. Copyright 2011 by The Cochrane Collaboration.
Suggested citation: Berger, S., Kaldenberg, J., Selmane, R., & Carlo, S. (2016). Effectiveness of interventions to address visual and visualperceptual impairments to improve occupational performance in adults with traumatic
brain injury: A systematic review (Suppl. Table 2). American Journal of Occupational Therapy, 70, 7003180010. http://dx.doi.org/10.5014/ajot.2016.020875

6
 Supplemental Table 3. Risk of Bias for Systematic Reviews Included in the Review
A Priori Duplicate Study Comprehensive Status of Publi- List of Included/ Characteristics of Quality of Studies Quality Assess- Methods Used to Likelihood of Conflict of
Design Selection/Data Literature Search cation as In- Excluded Studies Included Studies Assessed and ment Used Combine Results Publication Bias Interest
Citation Included? Extraction? Performed? clusion Criteria? Provided? Provided? Documented? Appropriately? Appropriate? Assessed? Stated?
Bouwmeester, 1 1 1 1 1 1 1 ?
Heutink, &
Lucas (2007)
Cicerone et al. 1 1 1 1 1
(2011)
Note. Responses to risk of bias questions: 1 5 low risk of bias; ? 5 unclear risk of bias; 5 high risk of bias. NA 5 not applicable.
Table format adapted from Development of AMSTAR: A Measurement Tool to Assess the Methodological Quality of Systematic Reviews, by B. J. Shea, J. M. Grimshaw, G. A. Wells, M. Boers, N. Andersson, C. Hamel, . . .
L. M. Bouter, 2007, BMC Medical Research Methodology, 7, p. 10.
Suggested citation: Berger, S., Kaldenberg, J., Selmane, R., & Carlo, S. (2016). Effectiveness of interventions to address visual and visualperceptual impairments to improve occupational performance in adults with traumatic
brain injury: A systematic review (Suppl. Table 3). American Journal of Occupational Therapy, 70, 7003180010. http://dx.doi.org/10.5014/ajot.2016.020875

The American Journal of Occupational Therapy, May/June 2016, Volume 70, Number 3
7
Reproduced with permission of the copyright owner. Further reproduction prohibited without
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