F-40 Auditory and visual rehabilitation
In the UK, social services provide services for people who are visually impaired, deaf, or deafblind. However, NHS audiology and ophthalmologic services offer diagnostic services, undertake medical or surgical treatments and provide glasses and hearing aids. Some ophthalmic departments offer low-vision rehabilitation services. Vision rehabilitation specialists belong to a professional body, the Rehabilitation Workers Professional Network. Social services employ Rehabilitation Officers (Hearing Impairment) to assist people with hearing impairment; no professional group exists. This separation from other rehabilitation services is unfortunate, not least because many people receiving rehabilitation will have impaired vision or hearing. A rehabilitation expert should know about the available services in Social Services, the Royal National Institute for Deaf People (RNID) and the Royal National Institute of Blind People (RNIB).
Table of Contents
The competency
The rehabilitation expert is “Able to assess visual and auditory impairments in the context of other rehabilitation needs to advise on what rehabilitation may reduce or ameliorate visual or auditory losses, and on how other rehabilitation should be modified to optimise benefit.” A downloadable document gives some indicative behaviours, knowledge, and skills associated with being competent. It also provides some references.
Introduction
Much of the brain is devoted to analysing visual and auditory input, and both are essential for communication and social interaction. While people without any impairment may think that deafness and blindness are binary, with someone being blind (or deaf) but otherwise having normal vision and hearing, both are commonly impaired, particularly in older people. This must always be considered and ameliorated.
Rehabilitation of these sensory impairments illustrates the General Theory of Rehabilitation well. Although some underlying diseases can be treated, the impaired function is generally unalterable. Nonetheless, much can be achieved to help the person adapt. Simple technologies such as glasses (spectacles) and hearing aids are usually the first step and can be remarkably effective. On the other hand, people with complete vision loss can be taught many techniques to increase mobility and social function.
Society also has a crucial role in ensuring that public environments are adapted to the needs of people with sensory impairment and people with limited mobility.
Many neurological conditions cause visual impairments secondary to alterations in processing visual stimuli. Phenomena such as hemianopia, visuospatial neglect, prosopagnosia (the inability to recognise faces), and other modifications in visual perception are often very disabling.
Auditory impairment also results from neurological conditions. Actual deafness or reduced auditory acuity may result from damage to the eighth cranial nerve but are otherwise uncommon. On the other hand, an inability to understand spoken speech (aphasia), auditory neglect, and disturbances in perception of music or other sounds may also arise from neurological disorders.
Many studies and services only consider visual impairment arising from a disease of the eye or optic nerve or hearing impairment from cochlear or auditory nerve lesions. Patients with other causes of reduced visual or auditory function are not considered.
Low-vision rehabilitation history.
Samuel Markowitz has written a brief, fascinating review of the development of low-vision rehabilitation, which I will summarise. Magnifying glasses were already used in China to assist reading when Marco Polo arrived in about 1275. He brought the idea back to Europe, and reading glasses were developed and used.
The Royal National Institute for the Blind was founded in the UK in 1868; Queen Victoria became its patron in 1875. After the First World War, more attention was given to blind people. People with low vision were classified as blind and, at that time, “strong advice was issued to save the residual vision by simply not using the eyes.”! Most attention was given to children. Institutions were founded to provide education and employment.
Low vision was recognised after the Second World War, and the first specialised low-vision clinics started in the United States in 1953. From the start, the services were multi-professional, including eye specialists and other professions. Despite this, another 30 years passed before the first international conference in 1986 and a definition of low-vision rehabilitation was agreed: “a multidisciplinary professional service that provides methods and means for optimal use of residual visual functions, training of residual vision-related skills, and reintegration in society.”
However, Samuel Markowitz notes that each profession’s guidance focuses on their contribution, leading to disintegration and loss of a uniform goal. Moreover, there is inadequate funding for services.
Last, he acknowledges the importance of rehabilitation for people with low vision secondary to neurological conditions such as stroke.
Evidence: visual rehabilitation.
Ruth van Nispen and colleagues undertook a Cochrane systematic review and meta-analysis of low vision rehabilitation for people with ocular low vision. Forty-four studies were identified. They investigated four types of intervention: psychological and group treatments, visual enhancement, multidisciplinary rehabilitation, and a miscellaneous category. The evidence needed to be stronger because studies were usually of low quality, treatments were ill-defined, and outcomes were difficult to compare. They concluded that the trend was toward benefit and that more research was justified and should be undertaken.
Alex Pollock and colleagues have completed three Cochrane systematic reviews on treatments for visual problems seen after stroke: visual field defects, age-related visual issues, and disordered eye movements:
- There is minimal evidence concerning rehabilitation for eye movement disorder. Only two studies were found, with only five of the 28 patients having had a stroke.
- Twenty studies, with data on 547 people with stroke, have examined treatment for visual field loss (hemianopia) after stroke. Training in visual scanning may benefit the person, but the evidence is weak. Other treatments, such as prisms, need more evidence to draw conclusions.
- There were no studies on age-related visual disorders in people with stroke.
People with poor or absent vision commonly use identification canes (“white sticks”). Judith Ballemans and colleagues reviewed the evidence on orientation and mobility training for partially sighted adults. No studies gave sound descriptions of training protocols or their evaluation. Rixt Zijlstra and colleagues (the same group) developed a standardised approach to orientation and mobility training, which has been published; the paper said it was being evaluated, but I cannot find the report from the randomised controlled trial.
Evidence: auditory rehabilitation
Hannah Cross and colleagues systematically reviewed evidence of hearing rehabilitation for care home residents with dementia. The interventions included sound amplification, written flashcards, and enhanced communication strategies, such as speaking more slowly or using non-verbal means. The techniques were effective in reducing the patients’ agitation, restlessness, and socially inappropriate behaviours.
Barriers to effective intervention identified included practical difficulties for patients using aids, insufficient staff time and training, and environmental factors. There were also facilitators, including family involvement, a culture in the care home of interdisciplinary collaboration and staff training, and a person-centred approach.
Another systematic review by David Hawkins investigated the Effectiveness of Counselling-Based Adult Group Aural Rehabilitation Programs. He concluded, “There is reasonably good evidence that participation in an adult AR program provides short-term reduction in self-perception of hearing handicap and potentially better use of communication strategies and hearing aids.” The relative effectiveness compared to using a hearing aid was not established.
People with refractive eye disorders can buy glasses without professional advice, which is common practice. However, the use of over-the-counter self-fitting hearing aids is rare, if allowed, in the UK at least. Karina De Sousa and her colleagues in South Africa undertook a randomised study comparing self-fitting and audiologist-fitted hearing aids in 64 adults with mild to moderate hearing loss. The outcomes were similar across the measures used.
A small proportion of all people with reduced hearing are children with congenital hearing loss. Parents are affected and may also be involved in helping their child adapt successfully. A scoping review to identify what early interventions might help found no good quality studies to guide best practice.
A synthesis on auditory and visual rehabilitation.
Rehabilitation helps people with impaired vision or hearing. Interventions rarely alter the underlying tissue damage or dysfunction; cataract surgery is one exception. Many people will not have considered the interventions part of rehabilitation so that I will enlarge upon this.
Equipment is effective – glasses and hearing aids restore function. Some patients require professional help, tailoring the lenses or hearing amplification to the person’s losses, although straightforward impairments may not need professional input. Guidance canes are essential for people with severe visual loss.
Teaching new techniques is effective. Though randomised trials are absent, giving a visually impaired person orientation, mobility training, and training in using a guide dog will help restore independence. Teaching people with severe hearing loss how to communicate using the appropriate sign language will also greatly help.
These rehabilitation activities help the person adapt, the central plank of the General Theory of Rehabilitation. Unfortunately, we have overlooked this great success, just as we overlooked the success of spinal cord injury rehabilitation.
Next, the environment dramatically impacts a person’s function if they have a visual or hearing impairment. Tom Shakespeare’s Social Model of Disability correctly highlights how society can increase or reduce the consequences of an impairment. We have made some advances for people with limited mobility or vision; noisy environments are still pervasive, and many people with hearing impairments have difficulty participating in restaurant conversations because they are too noisy.
Rehabilitation services can ensure that home environments are suitably adapted and could advocate for broader community changes.
Last, these services are entirely separated from other services; separating medical and rehabilitation services into two different organisations is a significant challenge to providing efficient and effective care. It also is a barrier to healthcare rehabilitation staff who wish to acquire experience in this field.
Conclusion
Most people working in healthcare rehabilitation will not have considered visual and auditory rehabilitation to be rehabilitation. Yet there are services to assist people to adapt to their impairments, just as we help people with acute spinal cord injury or motor neurone disease. Closer integration between the rehabilitation services and the healthcare services of ophthalmology and audiology and closer integration with healthcare rehabilitation service would likely improve care and research. Surprisingly, there is little research considering the importance of these two areas of practice.
