Environmental and behavioural interventions for reducing physical activity limitation in community-dwelling visually impaired older people

  • Review
  • Intervention

Authors


Abstract

Background

Impairment of vision is associated with a loss of function in activities of daily living. Avoidance of physical activity and consequent reduced functional capacity is common in older people with visual impairment and an important risk factor for falls. Indeed, the rate of falls and fractures is higher in older people with visual impairment than age-matched visually normal older people. Depression and anxiety is common in older people with vision impairment and leads to further restriction of activity, reduced social contact and reduced quality of life. Possible mechanisms to reduce activity restriction and therefore improve mobility and activity include environmental and behavioural interventions delivered by a number of health professionals, including occupational therapists.

Objectives

The objective of this review was to assess the effectiveness of environmental and behavioural interventions in reducing activity limitation and improving quality of life amongst visually impaired older people.

Search methods

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 10), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE, (January 1950 to November 2012), EMBASE (January 1980 to November 2012), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (January 1937 to November 2012), Allied and Complementary Medicine Database (AMED) (January 1985 to November 2012), OT Seeker (inception to November 2012), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 9 November 2012.

Selection criteria

Randomised controlled trials (RCTs) and quasi-randomised controlled trials (Q-RCTs) that compared environmental interventions, behavioural interventions or both, versus control (placebo control or no intervention or usual care), and trials comparing different types of environmental or behavioural interventions, in older people (aged 60 and over) with irreversible visual impairment living independently or in residential settings. To be eligible for inclusion the primary aim of studies must be reducing physical activity limitation and must include a measure of physical activity. Secondary outcome measures included falls, fear of falling, quality of life.

Data collection and analysis

Two authors independently read abstracts retrieved by the search to identify eligibility and study quality. We contacted study authors for additional information.

Main results

Our searches found no RCTs or Q-RCTs that met the eligibility criteria for this review.

Authors' conclusions

We are unable to reach any conclusion about the effectiveness of environmental or behavioural interventions for reducing physical activity limitation in community-dwelling visually impaired older people, as no eligible studies were found. However a number of studies reviewed included only the secondary outcome measures of this review. Although behavioural interventions delivered by occupational therapists have been shown to reduce the rate of falls, we are unable to conclude if this is due to reduced activity restriction (increased mobility) or reduced activity (lessening exposure to risk). There are inconclusive and conflicting results from trials evaluating the effectiveness of behavioural and environmental interventions aimed at improving quality of life. Further research is necessary (such as ongoing Dutch and UK trials considering the effectiveness of orientation and mobility training on activity restriction, physical activity, falls, fear of falling and quality of life in older adults with low vision, and the effect of an occupational therapist delivering home safety modification, coping strategies and exercise with older people with low vision) before any conclusions can be reached.

Résumé scientifique

Interventions environnementales et comportementales visant à réduire les limitations d'activité physique chez les personnes âgées souffrant de déficience visuelle et résidant dans la communauté

Contexte

La déficience visuelle est associée à une dégradation du fonctionnement dans les activités de la vie quotidienne. Le renoncement à des activités physiques, avec la baisse de capacité fonctionnelle qui s'en suit, est fréquente chez les personnes âgées souffrant de déficience visuelle et constitue un important facteur de risque de chute. En effet, le taux de chutes et de fractures est plus élevé chez les personnes âgées souffrant de déficience visuelle que chez les personnes du même âge à la vision normale. La dépression et l'anxiété sont fréquentes chez les personnes âgées atteintes de déficience visuelle, conduisant à une restriction supplémentaire de l'activité et réduisant les contacts sociaux et la qualité de vie. Les interventions environnementales et comportementales réalisées par un certain nombre de professionnels de la santé, comme les ergothérapeutes, sont des mécanismes possibles pour réduire la restriction d'activité et donc améliorer la mobilité et l'activité.

Objectifs

L'objectif de cette revue était d'évaluer l'efficacité des interventions environnementales et comportementales visant à réduire la limitation d'activité et à améliorer la qualité de vie des personnes âgées souffrant de déficience visuelle.

Stratégie de recherche documentaire

Nous avons effectué une recherche dans CENTRAL (qui contient le registre des essais cliniques du groupe Cochrane sur l'ophtalmologie) (The Cochrane Library 2012, numéro 10), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (de janvier 1950 à novembre 2012), EMBASE (de janvier 1980 à novembre 2012), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (de janvier 1937 à novembre 2012), Allied and Complementary Medicine Database (AMED) (de janvier 1985 à novembre 2012), OT Seeker (des origines à novembre 2012), le métaRegistre des essais contrôlés (mREC) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) et le système d'enregistrement international des essais cliniques de l'OMS (ICTRP) (www.who.int/ictrp/search/fr). Pour les recherches électroniques d'essais nous n'avons appliqué aucune restriction de date ou de langue. Nous avons consulté les bases de données électroniques pour la dernière fois le 9 novembre 2012.

Critères de sélection

Des essais contrôlés randomisés (ECR) et des essais contrôlés quasi-randomisés (Q-ECR) ayant comparé des interventions environnementales, des interventions comportementales ou les deux, à un groupe témoin (placebo, absence d'intervention ou soins habituels), et des essais ayant comparé différents types d'interventions environnementales ou comportementales, chez des personnes âgées (60 ans et plus) atteintes d'une déficience visuelle irréversible et vivant de façon autonome ou dans une résidence spécialisée. Pour que l'étude soit éligible à l'inclusion, son objectif principal devait être de réduire les limitations de l'activité physique et elle devait inclure une mesure de l'activité physique. Les critères de jugement secondaires comprenaient les chutes, la peur de tomber et la qualité de la vie.

Recueil et analyse des données

Deux auteurs ont indépendamment lu les résumés identifiés dans le processus de recherche afin de déterminer l'éligibilité et la qualité des études. Nous avons contacté des auteurs d'études afin d'obtenir des informations complémentaires.

Résultats principaux

Nous n'avons en fin de compte trouvé aucun ECR ou Q-ECR répondant aux critères d'éligibilité de cette revue.

Conclusions des auteurs

Aucune étude éligible n'ayant été trouvée, nous ne sommes pas en mesure de parvenir à une conclusion quant à l'efficacité des interventions environnementales ou comportementales visant à réduire les limitations de l'activité physique chez les personnes âgées souffrant de déficience visuelle et résidant dans la communauté. Toutefois, un certain nombre d'études examinées n'avaient rendu compte que des critères d'évaluation secondaires de cette revue. Bien que les interventions comportementales réalisées par des ergothérapeutes se soient avérées réduire le taux de chutes, nous ne sommes pas en mesure d'établir si cela est dû à la réduction des restrictions d'activité (mobilité accrue) ou à une réduction de l'activité (diminuant l'exposition au risque). Les résultats des essais ayant évalué l'efficacité des interventions comportementales et environnementales visant à améliorer la qualité de vie, sont contradictoires et non concluants. De nouvelles recherches sont nécessaires (comme les essais britanniques et néerlandais en cours étudiant l'efficacité de l'entrainement à l'orientation et à la mobilité quant à la restriction de l'activité, l'activité physique, les chutes, la peur de tomber et de qualité de vie chez les personnes âgées ayant une mauvaise vue, ainsi que l'effet de la prestation d'un ergothérapeute portant sur la modification de la sécurité domestique, les stratégies d'adaptation et l'exercice avec des personnes âgées ayant une mauvaise vue) avant que des conclusions puissent être formulées.

Plain language summary

Environmental and behavioural interventions to reduce activity limitation and improve quality of life in older people with visual impairment

Visual impairment in older people is associated with avoidance of physical activity, anxiety and depression as well as an increased risk of falls and fractures. Standard ways to improve vision-related quality of life include provision of glasses, filters and other vision-related equipment - in other words, interventions which generally make reading or watching television or using a computer more achievable. The use of behavioural strategies to improve a person's skill and confidence in activity or environmental changes in the home, work or leisure environment, such as improved lighting or highlighting stair edges, may help reduce activity restriction and improve quality of life, both outside and inside the home. We searched for evidence from high quality trials on environmental or behavioural interventions in older adults, living in the community or in residential settings, with irreversible vision impairment which aimed to reduce activity restriction or increase general physical activity. We found no trials that met the inclusion criteria for the review. Further research into this highly important issue needs to be done before any conclusions can be made.

Résumé simplifié

Interventions environnementales et comportementales visant à réduire les limitations d'activité et à améliorer la qualité de vie des personnes âgées souffrant de déficience visuelle

Chez les personnes âgées, la déficience visuelle est associée au renoncement à des activités physiques, à l'anxiété et à la dépression, ainsi qu'à un risque accru de chutes et de fractures. Les méthodes standard pour améliorer la qualité de vie liée à la vision sont notamment le port de lunettes, les filtres et autres équipements de vision - en d'autres termes, des interventions qui généralement améliorent la possibilité de lire, de regarder la télévision ou d'utiliser un ordinateur. L'utilisation de stratégies comportementales visant à améliorer les compétences d'activité et la confiance en elle de la personne ou à réaliser des changements dans l'environnement de la maison, du travail ou des loisirs, tels que l'amélioration de l'éclairage ou la mise en évidence des bords de marches d'escalier, pourrait aider à réduire la restriction d'activité et à améliorer la qualité de vie, tant à l'intérieur de la maison qu'à l'extérieur. Nous avons cherché des données dans des essais de bonne qualité sur des interventions environnementales ou comportementales visant à réduire la restriction d'activité ou à augmenter l'activité physique générale chez les personnes âgées vivant dans la communauté ou en résidence spécialisée, qui sont atteintes d'une déficience visuelle irréversible. Nous n'avons trouvé aucun essai remplissant les critères d'inclusion dans l'étude. Des recherches plus poussées sur cette question très importante seront nécessaires avant que des conclusions puissent être tirées.

Notes de traduction

Traduit par: French Cochrane Centre 16th July, 2013
Traduction financée par: Pour la France : Minist�re de la Sant�. Pour le Canada : Instituts de recherche en sant� du Canada, minist�re de la Sant� du Qu�bec, Fonds de recherche de Qu�bec-Sant� et Institut national d'excellence en sant� et en services sociaux.

Background

The prevalence of visual impairment is estimated by the World Health Organization (WHO) to be 161 million worldwide (Resnikoff 2008). One in eight people in the UK over the age of 75 and one in three over the age of 90 live with significant sight loss (Evans 2002). Older adults with visual impairment are more likely to be physically dependent, have poorer quality of life and are more likely to move into residential settings than their sighted peers (Ivers 1998; Klein 2003; Tinetti 1998). Impairment of vision is associated with a loss of function in activities of daily living (Brouwer 2008; Salive 1994). A UK report by Visibility (Campbell 2005a) found that older people with visual impairment are more likely to avoid activity due to their visual impairment. Anxiety and depression, leading to reduced activity, is common in those with visual impairment (Evans 2007). There is an association between vision and various health conditions and activity limitations among older people. These include decreases in leisure activities, Instrumental Activities of Daily Living (IADL) performance and social function, Activities of Daily Living (ADL) and compromised mobility. The International Classification of Functioning (ICF) defines activity as "the nature and extent of performance of a function by a person" and activity limitations as "problems of the performance of activities in nature, duration, and quality" (WHO 2001). The daily problems in seeking leisure activities by older adults with low vision may have implications for other health problems. Many older adults are not engaging in activities for which they may have sufficient vision due to factors unrelated to medical care. Inactivity and a lack of social connections should be noted by ophthalmologists and others treating the older population (Berger 2012). Challenging environments, struggling to obtain transportation, feelings of vulnerability, having decreased energy, and lacking assertiveness were all identified in interviews with older visually impaired adults as reasons for not being physically active and not feeling competent in such activities (Berger 2012).

Visual impairment is also associated with increases in the incidence of hip fractures, depression and falls (Crews 2004). Avoidance of physical activity due to fear of falling is common among older people at risk of falling (Yardley 2002). Indeed, the rate of falls in older people with visual impairment is 1.7 times higher, and hip fractures are 1.3 to 1.9 times higher than in age-matched visually normal populations (Legood 2002). One study reported that activity restriction was present in 45% of those with visual impairment, compared with only 24% in those without visual impairment who had experienced an injurious fall (Murphy 2002). Those with visual impairment were also more likely to admit to fear of falling (44%) even without a fall history. One study has shown that perceived interference of vision loss on goal-directed behaviour and expected activities has greater influence on distress and is subsequently predictive of disability in comparison with objective symptoms (visual acuity) (Dreer 2008). It therefore seems likely that the mechanism underpinning previous trials of maintaining mobility and physical activity, particularly with respect to environmental components, behavioural components or both, for people with visual impairment will be different from the general population. 

Description of the condition

Visual impairment is defined as best-corrected visual acuity of the better eye less than 0.3 logMAR (Log of the Minimum Angle of Resolution) units or visual field defects within 30 degrees of fixation. Blindness is defined as visual acuity less than 0.05 logMAR units or visual field defects within 10 degrees of fixation (WHO 1992). A working definition of visual impairment is low vision that cannot be corrected by standard glasses or by medical or surgical intervention. The top five conditions leading to visual impairment and blindness in the UK are age-related macular degeneration (AMD), glaucoma, diabetic retinopathy, myopic degeneration and optic atrophy (Evans 2004). Age-related macular degeneration and diabetic retinopathy are the most common causes of blindness in those over 65 years of age (Bamashmus 2004; Resnikoff 2004).

Description of the intervention

Environmental interventions include any targeted, intentional improvement to the (usually indoor) physical environment, with the aim of reducing symptoms or improving wellbeing (Preedy 2009). In the case of visual impairment, this may incorporate adaptations and modifications to an individual’s physical environment (usually their home) as the result of a formal environmental assessment that identified potential hazards or restrictions. The aim of the environmental intervention is to enhance the individual’s ability to perform daily living tasks safely and independently, facilitating their safe mobility and improving confidence. Examples for an individual with visual impairment include the removal of a rug, increased lighting in hallways and contrasting stripes on stairs.

Behavioural interventions include the systematic implementation of procedures that result in lasting positive changes in an individual's behaviour (Markowitz 2006a). 'Behavioural intervention' means the design, implementation, and evaluation of individual or group instructional and environmental modifications, including programmes of behavioural instruction, to produce significant improvement in human behaviour through skill acquisition and the reduction of problematic behaviour. These interventions, for people with visual impairment, might include, but are not restricted to, the teaching of adaptive strategies to enhance changes in an individual's behaviour when negotiating and interacting with their environment (Markowitz 2006b) and orientation and mobility (O&M) training (Virgili 2003). O&M training aims to teach the visually impaired person how to ambulate and negotiate the environment safely and independently and may contribute to reduced activity limitations and societal participation (Zijlstra 2009).

Occupational therapists, as a profession, have the expertise to assess, devise and implement rehabilitation plans which incorporate both types of interventions: an occupational therapy approach encompasses both environmental change and the interaction of the individual with their environment, their actions and their behavioural adaptations at home and in the community. This dynamic relationship between the person, their behaviour and the environment has been described elsewhere (Clemson 2003; Markowitz 2006b). Many environmental risk assessments, and some environmental modifications, are undertaken by other professionals but the relationship of the person, their behaviour and their environment may not be evaluated comprehensively.

How the intervention might work

Through changes in the home environment and behavioural strategies to negotiate the environment, the person with visual impairment may feel more confident that they can negotiate their environment safely, thereby reducing concerns about their safety and fear of falling. This should lead to greater mobility and habitual physical activity. This could be the mechanism behind previous trials that have shown reductions in falls in those with visual impairment following environmental and behavioural interventions (e.g. Campbell 2005b: La Grow 2006). Presentation of the information is also considered important and to be effective must be in collaboration with the person with visual impairment, in a problem-solving rather than prescriptive manner, to allow them ownership of the information and advice and to feel that it fits their abilities and preferences (Clemson 2008).

Why it is important to do this review

To date, no published literature review has been identified which specifically considers the effectiveness of environmental or behavioural interventions in reducing physical activity limitation among older people with visual impairment. The physiological, psychological, functional and societal benefits of regular physical activity amongst older people (WHO 2007) are irrefutable, and interventions that improve habitual physical activity in visually impaired older people are vital to promote public health. Trials which have adopted a holistic, participant-centred approach to environment modification (i.e. the consideration of the person within the context of the environment and their functional activities/demands) have shown reductions in falls both within and outside the home (Campbell 2005b; La Grow 2006), whereas trials that have considered removal of home hazards only (Stevens 2001) did not reduce the incidence of falls, even within the home. One potential mechanism for falls reduction could be that the visually impaired person actually restricts their activity more as a result of the intervention, which in the short term could reduce their exposure to falls risk (La Grow 2006). There is therefore a need to further unpick the mechanism of reduction in falls in visually impaired older people (La Grow 2006). Although interventions such as those aimed at reducing falls may work by increasing mobility and activity, they may also do the opposite. In one intervention, those allocated to exercise-only interventions, which had previously been shown to reduce falls in older people, had no reduction in their risk of falls (La Grow 2006). A sub-analysis of those who were compliant (performed the strength and balance exercises and walking programme) did show a reduction in risk. The authors hypothesised that visually impaired older people who engage in more activity reduce their risk, but those that avoid activity do not (La Grow 2006). Physical activity is known to have a U-shaped relationship to falls with those least and those most active more likely to fall (Gregg 2000). Trials rarely consider activity restriction or physical activity alongside falls as an outcome measure, so the mechanism remains unclear.

Although there is a previous systematic review of the effect of interventions to reduce falls in older adults (Gillespie 2012), there is no specific review in those with visual impairment. The rate of falls and injury is greater in older people with visual impairment than visually unimpaired older people (Legood 2002) and avoidance of activity is not uncommon in those with poor vision (Campbell 2005a). A previous systematic review on orientation interventions to improve mobility in people with visual impairment (Virgili 2003) considered performance in travel activities of daily life but not more generalised physical activity or activity restriction. Although there is some potential overlap in terms of secondary outcomes (quality of life and people’s perceptions of the effects of orientation interventions on their lives), this review included participants aged 16 and over, not older adults (aged 60 or over) with visual impairment. An ongoing Cochrane review (Langelaan 2007) considers multidisciplinary and monodisciplinary rehabilitation on generic health-related and vision-related quality of life. This review includes participants’ perception of the effect of rehabilitation on activities in daily living and on participation in society, so again there is potential overlap. However, the review includes participants aged 18 and over, not specifically older adults (aged 60 or over). 

Objectives

The objective of this review was to assess the effectiveness of environmental and behavioural interventions in reducing activity limitation and improving quality of life amongst visually impaired older people.

The following potential implications were also addressed in this review.

  • Do the interventions reduce activity restriction and increase physical activity and mobility in older people with visual impairment? What quality of life effects are there?

  • Do the interventions have the same effect in young-old and old-old, fallers and non-fallers, or those with different severity of visual impairment?

  • Do the mix and intensity of the interventions affect the outcome?

  • Do the interventions have different effects in different residential settings?

  • Does the training of the person delivering the interventions affect the outcome?

Methods

Criteria for considering studies for this review

Types of studies

We aimed to include randomised controlled trials (RCTs) and quasi-randomised controlled trials (Q-RCTs) that compared environmental interventions, behavioural interventions or both, versus control (placebo control or no intervention or usual care), and trials comparing different types of environmental or behavioural interventions. We did not include single studies that report only quality of life (as opposed to limitations in mobility and quality of life) so as to avoid overlap with another ongoing Cochrane review (Langelaan 2007).

Types of participants

We aimed to include trials with the following participants:

  • Older people (aged 60 and over) with irreversible visual impairment including, but not limited to, low visual acuity, poor contrast sensitivity, poor depth perception and reduced visual field.

  • Older people with irreversible visual impairment and other multiple disabilities, such as hearing loss, neurological or musculoskeletal disease or cognitive impairments. 

  • Older people living independently and those living in residential settings.

Types of interventions

Environmental interventions, behavioural interventions or both, including but not limited to visual rehabilitation (e.g. low vision devices), removal of home hazards, home safety modifications, provision of adaptive or assistive equipment, advice on behavioural changes to improve safety in activities of daily living (IADL and ADL), cognitive behavioural therapies, or other behavioural therapies aimed at changing behaviour.

For any study included, we aimed to record the professional training of the person delivering the interventions. The types of interventions would also be rated on the intensity of the intervention, based on previously published criteria (evaluation of risk of person and environment; validated assessment tools; formal or observational evaluation of functional capacity; and adequate follow-up) (Clemson 2008).

We did not include other vision-correction interventions (e.g. cataract surgery, corrective lenses or filters) in this review.

Types of outcome measures

Primary outcomes

To be eligible for inclusion the primary aim of the study was to reduce physical activity limitation and needed to include a measure of physical activity which might include the following:

  • Continuous objective measures e.g. body fixed sensor activity monitoring.

  • Continuous subjective self report measures e.g. validated questionnaires such as Physical Activity Scale for the Elderly (PASE), Community Healthy Activities Model Program for Seniors (CHAMPS).

  • Other self-reporting measures may be dichotomous e.g. single questions on physical activity.

Secondary outcomes
  • Falls (rate (or number) of falls or number of fallers) and fall-related injuries. Prospective daily calendars returned monthly for at least one year is the preferred method for recording falls (Lamb 2005).

  • Fear of falling (e.g. scales such as FES-I, ABC, FES, MFES, FHI, SAFFE and Single Item 1-4).

  • Quality of life (e.g. Euroquol, SF12, SF36, WHOQoL or any other validated means of recording subjective QOL).

  • Attitudes, beliefs and behaviours (e.g. AFRIS, OEE, SEE, FaB). The latter may also be ascertained via qualitative methods such as focus groups and interviews.

Search methods for identification of studies

Electronic searches

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2012, Issue 10, part of The Cochrane Library. www.thecochranelibrary.com (accessed 9 November 2012), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE, (January 1950 to November 2012), EMBASE (January 1980 to November 2012), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (January 1937 to November 2012), Allied and Complementary Medicine Database (AMED) (January 1985 to November 2012), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 9 November 2012.

We found that searches in PsycINFO, Applied Social Sciences Index and Abstracts (ASSIA), Sociological Abstracts (SocioFILE), Science Citation Index, Social Sciences Citation Index, did not yield any additional papers and we were unable to choose specific criteria to search for our inclusion criteria so it was decided that the databases searched above would give sufficient coverage. There were no date or language restrictions in the electronic searches for trials.

See: Appendices for details of search strategies for CENTRAL (Appendix 1), MEDLINE (Appendix 2), EMBASE (Appendix 3), CINAHL (Appendix 4), AMED (Appendix 5), OTseeker (Appendix 6), mRCT (Appendix 7),ClinicalTrials.gov (Appendix 8) and the ICTRP (Appendix 9).

Searching other resources

We contacted authors of any ongoing trials or abstracts found and searched the reference lists of full papers reviewed, as identified in our electronic search.

Data collection and analysis

Selection of studies

Two review authors (DS and CB), working independently, screened all titles and abstracts generated by the searches for potentially relevant studies. We based the decision as to whether to include studies on the following criteria: the type of study; type of participants; type of intervention and type of outcome measurements. Two review authors (DS and TH) assessed the full-text articles of the selected titles and abstracts for eligibility according to the 'Criteria for considering studies for this review' outlined above. We resolved disagreements by consensus. In one instance (where an abstract only was found) we sought additional information from the author; however, the full paper had not been published and the study did not meet the inclusion criteria.

Data extraction and management

We planned that when a study fulfilled the inclusion criteria, data concerning methodological issues, characteristics of participants, interventions and outcome measures would be independently extracted using a standard extraction form and the review authors would not be masked to the study’s authors, institutions or journal of publication. Where available and appropriate, we would have presented quantitative data for the outcomes listed in the inclusion criteria in the analyses. Where studies report standard errors of the means (SEMs), we would obtain standard deviations (SDs) by multiplying SEMs by the square-root of the sample size. We would have attempted to contact authors of studies where there was inadequate reporting of data to enable clarification and where appropriate, to allow pooling.

Assessment of risk of bias in included studies

We planned, if there were included RCTs, for two review authors to independently assess risk of bias in included studies using the methodology described in Chapter 8 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). The studies would have been assessed on the following criteria: random sequence generation, allocation concealment, masking (blinding) of participants and personnel, masking of outcome assessment, incomplete outcome data, selective outcome reporting and other sources of bias. Due to the nature of this intervention it is not possible to mask participants or staff providing the intervention. It is however possible to mask outcome assessors for objective measurements. Authors’ assessments were to be 'High risk of bias', 'Low risk of bias' or 'Unclear risk of bias'.

Measures of treatment effect

For each trial, we would have calculated a risk ratio (RR) and 95% confidence interval (CI) for dichotomous outcomes, and weighted mean differences (WMD) and 95% CI for continuous outcomes (reporting mean and SD or SEM). We would have calculated standardised mean differences (SMDs) and 95% CIs when combining results from studies using different ways of measuring the same concept. We would have reported change scores separately as these cannot be incorporated into meta-analyses of SMDs. Where appropriate, we would have pooled results of comparable groups of trials using the fixed-effect model and would have calculated the 95% CIs.

Unit of analysis issues

We planned to report the level at which randomisation occurred in the included studies as specified in Chapter 9 of the Cochrane Handbook for Systematic Reviews of Interventions (Deeks 2011). Possible variations in study designs include cluster-randomised trials, cross-over trials, multiple treatments and multiple intervention groups. We would not have applied thresholds for eligibility (e.g. outcomes masked to allocation or minimum follow-up period) but would have reported details of the studies which may have affected interpretation of the data (e.g. short duration of intervention).

Dealing with missing data

If missing data were discovered during data extraction, we planned to contact the original investigators of the study to request the required information. It might also have been necessary to conduct a sensitivity analysis if assumptions had been made (Deeks 2011). We planned to describe the potential effect of missing data upon conclusions drawn from this review.

Assessment of heterogeneity

We would have tested heterogeneity between comparable trials after due consideration of the value of I²; a value greater than 50% may indicate substantial heterogeneity (Higgins 2003). We would also have considered methodological and clinical heterogeneity. In the presence of heterogeneity, depending on the number of studies and the direction of effect, we would have pooled the results of comparable groups of trials using the random-effects model and would have calculated the 95% CIs or have considered the subgroup analyses described later.

Assessment of reporting biases

We would have tested publication bias using funnel plots or other corrective analytical methods, provided there was a sufficient number of trials included in the systematic review. We would have reviewed and discussed open and uncontrolled studies to identify reporting bias.

Data synthesis

Where appropriate, we would have pooled results of comparable groups of studies using the fixed-effect model and calculated 95% CIs. In the presence of heterogeneity, we would have pooled the results of comparable groups of trials using the random-effects model and calculated 95% CIs. In the case of methodological (including unit of analysis issues) or clinical heterogeneity, we would have undertaken sensitivity analyses to examine the impact of these studies on the results.

Subgroup analysis and investigation of heterogeneity

The review authors planned to consider the following hypotheses using subgroup analysis if sufficient data were available:

  1. Behavioural interventions delivered in tandem with environmental interventions are more effective than either behavioural or environmental interventions delivered on their own.

  2. Interventions are equally effective on differing severities of visual impairment.

  3. Interventions are equally effective with fallers as they are with the general older population (inclusion criteria at point of recruitment into the study).

Sensitivity analysis

We planned to undertake sensitivity analyses, where indicated, to investigate the effects of methodological quality. For example, if appropriate, we would have looked at the effect of excluding quasi-randomised trials, as they will be at higher risk of bias. Many issues suitable for sensitivity analysis are only identified during the review process where the individual peculiarities of the studies under investigation are identified. As no studies have been identified for inclusion in this review, we are unable to undertake such analyses.

Grading of evidence and summary of findings table

We planned to present major outcomes (including benefits and adverse events) in a 'Summary of findings' table, which provides information on the quality of evidence and the magnitude of the intervention effect, as well as a summary of the main outcome data as described in Chapter 11 of the Cochrane Handbook for Systematic Reviews of Interventions (Schünemann 2011). We would also have presented an assessment of the overall quality of evidence per outcome (high, moderate, low and very low) using the GRADE approach (Schünemann 2011). We also planned to review the cost of treatment in the included studies and other publications.

Results

Description of studies

Results of the search

The electronic searches yielded a total of 6014 references from electronic databases and two records from screening the citations from potentially relevant references. One ongoing study was known to the authors but not found in the searches of the included databases (UKCRN ID 10883). The Trials Search Co-ordinator scanned the search results, removed duplicates and trial protocols, and removed 4330 references which were not relevant to the scope of the review. The authors screened the remaining 780 published reports to identify potentially relevant studies. We obtained full-text copies of 30 studies for further investigation. After reading the full-text record we excluded all the studies. See Figure 1.

Figure 1.

Results from searching for studies for inclusion in the review.

Three of the trials identified on the clinicaltrials.gov website may be of interest to a future update of this review. The first aims to demonstrate how specified physical and emotional outcomes of persons with low vision change across time, with an RCT of a sham versus a problem-solving intervention. We await the publication of this trial (recruitment due to end Oct 2011) (NCT00545220). The second trial has an intervention where a low vision occupational therapist collaborates with a low vision optometrist to develop and implement a care plan based on a person's vision status, rehabilitation potential, and personal rehabilitation goals - but outcome measures only targeted vision function and vision-related quality of life. We await the publication of this trial (recruitment due to end July 2012) (NCT00769015), to see if there are any outcomes of interest within vision-related quality of life. Finally, a study in the Netherlands which has relevant outcome measures (Zijlstra 2009) is ongoing. See Characteristics of ongoing studies.

Although removed at the screening stage, two other ongoing studies were identified in the searches. One Australian study (published protocol) is considering the effects of a low vision programme on 'positive and active engagement with life' (ACTRN12607000399493). The other study was identified through contacts of the authors. Based in the UK (UKCRN ID 10883), this pilot (RCT) study, VIP2UK, aims to promote adherence to an occupational therapy and exercise intervention to reduce falls in older people with visual impairment. See Characteristics of ongoing studies.

Included studies

No studies met the criteria for this review (see Figure 1).

Excluded studies

From the reports, we selected 30 studies for review in full text, but excluded all of them. Eight studies were not behavioural or environmental interventions aimed at increasing activity or reducing activity restriction; instead they were visual field training (Balliet 1985); residual vision training (Conrod 1986); feature search task (computerised vision training) (Kuyk 2010); perceptual learning (paper-based) (Overbury 1996); use of microscopes to extend reading time (Scanlan 2004); eccentric viewing computerised intervention (Vukicevic 2009); educational programme to improve self care, food preparation, home and financial management (Smith 2009). One study was aimed at improving skills at requesting on-the-job accommodations from employers and therefore had very few participants in the eligible age range (Rumrill 1999).

Of those interventions that were eligible (included an environmental or behavioural component), four were not RCTs (Gutman 2002; Kuyk 2008; La Grow 2004; McCabe 2000) and had no activity outcomes. One other was not an RCT but potentially had a physical activity outcome of interest but this was a single question on moderation of physical activity, questions on walking in and out of the home and use of transport (Engel 2000). The study was not controlled, did not report standard deviations (SDs) so as to assess effect size and had considerable drop out (Engel 2000). One other was not an RCT, but rather an implementation paper (how to implement the intervention) based on Campbell 2005b (La Grow 2006). Two were abstracts which were actually the protocols for studies (Stelmack 2005; West 2004) and had no activity outcomes. Fourteen did not have any outcome measures of interest in this review (e.g. physical activity/activity restriction). Instead these studies had outcome measures such as falls and injuries (Campbell 2005b; Cumming 2007; Day 2002); perceived security in the performance of daily occupations (Dahlin-Ivanoff 2002); participation in daily activities (as opposed to physical activity) (Girdler 2010); reading skills (Stelmack 2008a; Stelmack 2008b; Stelmack 2008c); improve quality of life (Reeves 2004) or wellbeing (Pankow 2004); improved physical function (Deremeik 2007; Pankow 2004); associations between assistive devices and activities of daily living (Eklund 2007); dependence in activities of daily living (Eklund 2008; Reeves 2004); and balance (Cheung 2008). Although Cheung 2008 also had as an aim to increase confidence in safe ambulation, this was not assessed as an outcome.

All trials which considered environmental or behavioural interventions were with older people living in the community, except the SEEING trial (Deremeik 2007) and West 2004, which were based in nursing homes.

Risk of bias in included studies

There were no studies included in this review.

Effects of interventions

Our searches produced no RCTs or quasi-RCTs of behavioural or environmental interventions to reduce activity restriction and improve quality of life in older people with vision impairment that met our eligibility criteria.

Discussion

Although this could be considered an ‘empty review’, there is value in publishing a review without includable studies, as it indicates the state of research evidence at a particular point in time and highlights major research gaps (Lang 2007). There is value in such reviews in informing clinicians, consumers, and other decision makers in health care when there is lack of robust evidence for or against a healthcare intervention (Green 2007).

It is important to note that, although we reviewed 14 RCTs of environmental and behavioural interventions in older people with visually impairment, none of these had an outcome measure that gauged their effectiveness on physical activity or physical activity restriction. Some studies included outcome measures of participation in daily activities (as opposed to physical activity) (Girdler 2010); perceived security in performing occupations (Dahlin-Ivanoff 2002); associations between assistive devices and activities of daily living (Eklund 2007); or dependence in activities of daily living (Eklund 2008; Reeves 2004), which perhaps are markers or would be associated with activity restriction, but were not listed in our a priori outcome measures. All of these studies included occupational therapists or vision rehabilitation officers as the professionals delivering the intervention. Quality of life (Girdler 2010; Reeves 2004), wellbeing (Pankow 2004) or improvements in physical function (Deremeik 2007; Pankow 2004) were the other outcome measures of interest. One suite of studies concentrated on reading skills (Stelmack 2008a; Stelmack 2008b; Stelmack 2008c). Other studies assessed the interventions' effectiveness on balance (Cheung 2008) or falls and injuries (Campbell 2005b; Cumming 2007; Day 2002). However, it is not possible to know if a reduction in falls risk is due to the participants' reduced activity (so reducing their exposure to risk) or their becoming better able to cope with their environment. It would have been useful to have assessed whether falls per unit of activity (or exposure) were reduced in these studies as per the guidelines of ProFaNE (Lamb 2005). Interestingly, Reeves 2004 showed no positive benefit of their intervention on quality of life and concluded that researchers should be aware that, in people with macular degeneration at least, the determinants of quality of life may revolve more around lost sources of pleasure and relaxation (e.g. playing with grandchildren or reading) than in their ability to perform essential activities in a constrained way. In other words, the value of reducing activity restriction is important to patients.

A recent systematic review (Binns 2012) reminds researchers that outcome measures chosen to determine the effectiveness of low vision services should reflect capacity within daily activities, within the home environment, rather than just on clinical outcomes. These reviewers, although including non-RCTs, only found seven trials, and whilst they felt able to confirm that rehabilitation services result in improved clinical and functional outcomes, they commented that the number of studies meeting their inclusion criteria was ‘pitifully small’. There is growing interest in physical activity in those living with low vision as reflected by a recent study considering the accuracy and validity of talking pedometers to measure activity in people with visual impairment (Holbrook 2011). Trials which consider both subjective and objective physical activity and activity restriction are necessary to see if interventions can make a difference to habitual physical activity.

However, we did find one ongoing RCT which is assessing orientation and mobility (O&M) training in older people with low vision and has activity restriction as an outcome measure (Zijlstra 2009). We also await an ongoing pilot RCT (UKCRN ID 10883) of increasing adherence to an occupational therapy-delivered home safety and modification programme and an occupational therapist-delivered home exercise programme, with physical activity as a core outcome measure. We also await with interest the publication of results from an Australian study which is considering the effects of a low vision programme on 'positive and active engagement with life' (ACTRN12607000399493), and two American studies where it is unclear whether the outcome measures will meet our criteria (NCT00769015; NCT00545220). See 'Characteristics of ongoing studies'.

Of final note is the concern that interventions are rarely described in detail, nor do they provide information on the most appropriate participant groups or types of visual impairment with which they are most effective. It is important to customise interventions to suit particular individuals and their needs and preferences. A 'black box' of multiple interventions makes it difficult to pull out the effectiveness of differing parts of the interventions (e.g. a mix of environmental and behavioural interventions may make it difficult to disentangle which type of intervention is more appropriate for which participant group).

Summary of main results

Our searches produced no RCTs or quasi-RCTs of behavioural or environmental interventions to reduce activity restriction and improve quality of life in older people with vision impairment that met our eligibility criteria.

Potential biases in the review process

We attempted to minimise bias by two review authors independently reviewing the titles and abstracts. We did not restrict the articles to English only so we should have minimised publication bias. It is possible that our search terms were not broad enough, or were restrictive. However all studies that the authors were aware of were picked up in the searches. The search for this review was completed in November 2012. It is possible that relevant studies have been published in the interim period to publication but to counter this, we will update the review bi-annually. We deliberately did not narrow our population group and included both community-dwelling and care home/residential older adults so we do not feel that we were too narrow in our approach to the population group. It is possible that we were too precise in our interventions by excluding, for example, computerised visual field or eccentric view training but the focus of this review was to consider modifications to the home environment, and coping and enabling strategies to negotiate safely in and out of the home. We excluded one study which considered perceived security in performing occupational activities and it could be countered that this would reflect activity restriction, but this was not set a priori in the protocol. As no studies met the selection criteria we can only comment that there is so far no evidence of effect.

Agreements and disagreements with other studies or reviews

The Cochrane review Virgili 2003 considered the effectiveness of O&M training in adults with low vision. The review included two small trials comparing O&M training to physical exercise, which provided weak evidence. O&M training had no effect in one study while it was found to be beneficial in the second. There is therefore little evidence on which type of O&M training is better for people with low vision who have specific characteristics and needs.

Work commissioned by the Thomas Pocklington Trust (Ballinger 2009) aimed to carry out a qualitative evidence synthesis of qualitative research exploring the views and experiences of older people with visual impairment on participation in falls prevention initiatives. Although no studies were found which explicitly sought to explore the views of older visually impaired people per se, three studies were included as all had relevant data which could be considered, although the potential for synthesis was limited. The single theme extending across all three studies was the capacity and desire for autonomous decision-making around environmental modification by older people with visual impairment, informed by but not dependent on the recommendations of others such as health professionals. Other themes elicited from one or two studies included: the influence of function, ambiance, safety, cleanliness and use of cues in decision-making about environmental modification.

Although there is a previous systematic review of the effect of interventions to reduce falls in older adults (Gillespie 2012), there is no specific review of those with visual impairment. However, Gillespie 2012 did show that home safety interventions were more effective in reducing rate of falls in the higher risk subgroup of older people. They also found that there was some evidence that occupational therapy-led interventions on home safety assessment were more effective than non-occupational therapy-led interventions for reducing rate of falls.

Authors' conclusions

Implications for practice

We are unable to reach any conclusion as to the evidence behind the effectiveness of environmental or behavioural interventions for reducing physical activity limitation in community-dwelling visually impaired older people, as no eligible studies were found. However, the fact that we have been unable to show a lack of evidence of effect does not mean there is no effect, merely that there are no eligible studies addressing this issue.

A number of studies reviewed included only the secondary outcome measures of this review. Although behavioural interventions delivered by occupational therapists have been shown to reduce the rate of falls, we are unable to conclude if this is due to reduced activity restriction (increased mobility) or reduced activity (lessening exposure to risk). There are inconclusive and conflicting results arising from the evaluation of behavioural and environmental interventions aimed at improving quality of life. This is perhaps because many intervention studies have not focused on coping strategies to engage with leisure activities and have instead focused on essential activities of daily living.

As restricted activity can lead to declining mobility, to distress and anxiety, and to an increased risk of falls, healthcare professionals need to consider ways to facilitate people to increase physical activity and help remove the barriers to activity in older people with visual impairment.

Implications for research

There is a gap in knowledge concerning the effectiveness of behavioural and environmental interventions in reducing activity restriction and improving quality of life in older people with irreversible vision loss. Further research, such as ongoing Dutch, Australian and UK trials, considering the effectiveness of orientation and mobility training on activity restriction, physical activity, falls, fear of falling and quality of life in older adults with low vision, are necessary before any conclusions can be reached.

Acknowledgements

The review authors would like to acknowledge the Cochrane Eyes and Vision Group (CEVG), in particular, Anupa Shah for her patience and detailed help, and Iris Gordon, Trials Search Co-ordinator, for compiling the search strategy and searches and to Marion Kelt (Librarian, Glasgow Caledonian University) for her help in local searches. They would like to thank the Thomas Pocklington Trust for part funding the review and Dr Senay Aydin for help in retrieving the papers for review by the authors. Finally, they would like to thank Gianni Virgili (author of the Orientation and mobility training for adults with low vision Cochrane Review) and Maaike Langelaan (author of the Multidisciplinary rehabilitation and monodisciplinary rehabilitation for visually impaired adults Cochrane Review) for help in ensuring our review protocol was complementary to theirs, and Catey Bunce and Giovanni Sato for their comments on the protocol for this review, and Jennifer Evans and Giavanni Giacomelli for their comments on the full review.

Richard Wormald (Co-ordinating Editor for CEVG) acknowledges financial support for his CEVG research sessions from the Department of Health through the award made by the National Institute for Health Research to Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology for a Specialist Biomedical Research Centre for Ophthalmology.

The views expressed in this publication are those of the authors and not necessarily those of the NIHR, NHS or the Department of Health.

Data and analyses

Download statistical data

This review has no analyses.

Appendices

Appendix 1. CENTRAL search strategy

#1 MeSH descriptor Vision Disorders
#2 MeSH descriptor Visually Impaired Persons
#3 (low* or handicap* or subnormal* or impair* or partial* or disab*) near/3 (vision or visual* or sight*)
#4 (#1 OR #2 OR #3)
#5 MeSH descriptor Rehabilitation
#6 (rehabilitat* or assess*) near/4 (low vision)
#7 MeSH descriptor Activities of Daily Living
#8 MeSH descriptor Risk Assessment
#9 MeSH descriptor Risk Factors
#10 MeSH descriptor Risk Management
#11 MeSH descriptor Safety Management
#12 (home near/3 safet*)
#13 (hazard*) near/3 (home or environment*)
#14 MeSH descriptor Home Care Services
#15 MeSH descriptor Occupational Therapy
#16 MeSH descriptor Exercise Therapy
#17 MeSH descriptor Physical Therapy Modalities
#18 behavio* near/3 modif*
#19 (program*) near/3 (home or exercise* or modif*)
#20 MeSH descriptor Cognitive Therapy
#21 MeSH descriptor Behavior Therapy
#22 (#5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17 OR #18 OR #19 OR #20 OR #21)
#23 (#4 AND #22)

Appendix 2. MEDLINE (OvidSP) search strategy

1. randomized controlled trial.pt.
2. (randomized or randomised).ab,ti.
3. placebo.ab,ti.
4. dt.fs.
5. randomly.ab,ti.
6. trial.ab,ti.
7. groups.ab,ti.
8. or/1-7
9. exp animals/
10. exp humans/
11. 9 not (9 and 10)
12. 8 not 11
13. exp vision disorders/
14. exp visually impaired persons/
15. ((low$ or handicap$ or subnormal$ or impair$ or partial$ or disab$) adj3 (vision or visual$ or sight$)).tw.
16. or/13-15
17. exp rehabilitation/
18. ((rehabilitat$ or assess$) adj4 low vision).tw.
19. exp activities of daily living/
20. risk assessment/
21. risk factors/
22. risk management/
23. safety management/
24. (home adj3 safety$).tw.
25. (hazard$ adj3 (home or environment$)).tw.
26. home care services/
27. occupational therapy/
28. exercise therapy/
29. physical therapy modalities/
30. (behavio$ adj3 modif$).tw.
31. (program$ adj3 (home or exercise$ or modif$)).tw.
32. Cognitive Therapy/
33. Behavior Therapy/
34. or/17-33
35. 16 and 34
36. 12 and 35

The search filter for trials at the beginning of the MEDLINE strategy is from the published paper by Glanville et al (Glanville 2006).

Appendix 3. EMBASE (OvidSP) search strategy

1. exp randomized controlled trial/
2. exp randomization/
3. exp double blind procedure/
4. exp single blind procedure/
5. random$.tw.
6. or/1-5
7. (animal or animal experiment).sh.
8. human.sh.
9. 7 and 8
10. 7 not 9
11. 6 not 10
12. exp clinical trial/
13. (clin$ adj3 trial$).tw.
14. ((singl$ or doubl$ or trebl$ or tripl$) adj3 (blind$ or mask$)).tw.
15. exp placebo/
16. placebo$.tw.
17. random$.tw.
18. exp experimental design/
19. exp crossover procedure/
20. exp control group/
21. exp latin square design/
22. or/12-21
23. 22 not 10
24. 23 not 11
25. exp comparative study/
26. exp evaluation/
27. exp prospective study/
28. (control$ or prospectiv$ or volunteer$).tw.
29. or/25-28
30. 29 not 10
31. 30 not (11 or 23)
32. 11 or 24 or 31
33. exp vision disorder/
34. exp visual impairment/
35. ((low$ or handicap$ or subnormal$ or impair$ or partial$ or disab$) adj3 (vision or visual$ or sight$)).tw.
36. or/33-35
37. exp rehabilitation/
38. ((rehabilitat$ or assess$) adj4 low vision).tw.
39. exp daily life activities/
40. risk assessment/
41. risk factor/
42. exp home safety/
43. (home adj3 safety$).tw.
44. exp falling/
45. (hazard$ adj3 (home or environment$)).tw.
46. home care/
47. occupational therapy/
48. kinesiotherapy/
49. exp physiotherapy/
50. (behavio$ adj3 modif$).tw.
51. (program$ adj3 (home or exercise$ or modif$)).tw.
52. Cognitive Therapy/
53. Behavior Therapy/
54. or/37-53
55. 36 and 54
56. 32 and 55

Appendix 4. CINAHL (EBSCO) search strategy

S42 S40 and S41
S41 (MH "Aged+") OR (MH "Aged, 80 and Over") OR (MH "Frail Elderly")
S40 S12 and S39
S39 S20 and S38
S38 S21 or S22 or S23 or S24 or S25 or S26 or S27 or S28 or S29 or S30 or S31 or S32 or S33 or S34 or S35 or S36 or S37
S37 (MH "Behavior Therapy+") OR (MH "Behavior Therapy (Iowa NIC) (Non-Cinahl)")
S36 (MH "Cognitive Therapy") OR (MH "Cognitive Therapy (Iowa NIC) (Non-Cinahl)")
S35 TX ((program* n3 home) or (program* n3 exercise) or (program* n3 modif*))
S34 TX behavio* n3 modif*
S33 (MH "Physical Therapy")
S32 (MH "Exercise Therapy: Ambulation (Iowa NIC)") OR (MH "Exercise Therapy: Balance (Iowa NIC)")
S31 (MH "Occupational Therapy+")
S30 (MH "Home Health Care")
S29 TX ((hazard* n3 home) or (hazard* n3 environment*))
S28 TX home n3 safety*
S27 (MH "Risk Management") OR (MH "Risk Management (Iowa NIC) (Non-Cinahl)")
S26 (MH "Risk Factors")
S25 (MH "Risk Assessment") OR (MH "Fall Risk Assessment Tool")
S24 (MH "Activities of Daily Living+") OR (MH "Activities of Daily Living (Saba CCC)") OR (MH "Activities of Daily Living Alteration (Saba CCC)") OR (MH "Instrumental Activities of Daily Living (Saba CCC)") OR (MH "Instrumental Activities of Daily Living Alteration (Saba CCC)") OR (MH "Altered Activities of Daily Living (NANDA) (Non-Cinahl)") OR (MH "Self Care: Activities of Daily Living (Iowa NOC)") OR (MH "Self-Care: Instrumental Activities of Daily Living (Iowa NOC)")
S23 TX assess* n4 vision*
S22 TX rehabilitat* n4 vision*
S21 (MH "Rehabilitation of Vision Impaired+")
S20 S13 or S14 or S15 or S16 or S17 or S18 or S19
S19 TX ((disab* n3 vision) or (disab* n3 visual*) or (disab* n3 sight))
S18 TX ((partial* n3 vision) or (partial* n3 visual*) or (partial* n3 sight))
S17 TX ((impair* n3 vision) or (impair* n3 visual*) or (impair* n3 sight))
S16 TX ((subnormal* n3 vision) or (subnormal* n3 visual*) or (subnormal* n3 sight))
S15 TX ((handicap* n3 vision) or (handicap* n3 visual*) or (handicap* n3 sight))
S14 TX ((low* n3 vision) or (low* n3 visual*) or (low* n3 sight))
S13 (MH "Vision Disorders+")
S12 S1 or S2 or S3 or S4 or S5 or S6 or S7 or S8 or S9 or S10 or S11
S11 TX allocat* random*
S10 (MM "Quantitative Studies")
S9 (MM "Placebos")
S8 TX placebo*
S7 TX random* allocat*
S6 (MM "Random Assignment")
S5 TX randomi* control* trial*
S4 TX ( (singl* n1 blind*) or (singl* n1 mask*) ) or TX ( (doubl* n1 blind*) or (doubl* n1 mask*) ) or TX ( (tripl* n1 blind*) or (tripl* n1 mask*) ) or TX ( (trebl* n1 blind*) or (trebl* n1 mask*) )
S3 TX clinic* n1 trial*
S2 PT Clinical trial
S1 (MH "Clinical Trials+")

Appendix 5. AMED (OvidSP) search strategy

1. vision disorders/
2. ((low$ or handicap$ or subnormal$ or impair$ or partial$ or disab$) adj3 (vision or visual$ or sight$)).tw.
3. or/1-2
4. Rehabilitation/
5. ((rehabilitat$ or assess$) adj4 low vision).tw.
6. "Activities of daily living"/
7. Risk/
8. Safety/
9. (home adj3 safety$).tw.
10. (hazard$ adj3 (home or environment$)).tw.
11. Home care services/
12. Occupational therapy/
13. Exercise therapy/
14. physical therapy modalities/
15. (behavio$ adj3 modif$).tw.
16. (program$ adj3 (home or exercise$ or modif$)).tw.
17. Cognitive therapy/
18. Behavior therapy/
19. or/4-18
20. 3 and 19
21. "Randomized controlled trials"/
22. prospective studies/
23. single blind method/
24. random$.tw.
25. placebo$.tw.
26. trial$.tw.
27. groups.tw.
28. ((singl$ or doubl$) adj3 (blind$ or mask$)).tw.
29. or/21-28
30. 20 and 29

Appendix 6. OTseeker search strategy

low vision AND rehabilitation AND random

Appendix 7. metaRegister of Controlled Trials search strategy

low vision and rehabilitation

Appendix 8. ClinicalTrials.gov search strategy

Low Vision AND Rehabilitation

Appendix 9. ICTRP search strategy

Low Vision AND Rehabilitation

Contributions of authors

Skelton, Ballinger, Neil and Howe conceived and developed the protocol. Gray and Palmer commented on drafts of the protocol and search strategies. Skelton and Howe reviewed all selected publications, with Gray as adjudicator. Ballinger, Howe, Palmer and Gray commented on drafts of the review.

Declarations of interest

None known.

Sources of support

Internal sources

  • Visibility, UK.

    Salary SP

  • Southampton University, UK.

    Salary CB

  • Glasgow Caledonian University, UK.

    Salary DS, TH, LG

  • NHS Greater Glasgow & Clyde, UK.

    Salary FN

External sources

  • Thomas Pocklington Trust, UK.

    Partial financial support (CB) for review

Differences between protocol and review

Our search strategy changed slightly - see 'Electronic searches' section earlier.

Notes

The protocol and review has had slight amendment to the a priori subgroup analyses. The review authors planned to consider the following hypotheses for subgroup analysis if sufficient data were available:

  1. Behavioural interventions delivered in tandem with environmental interventions are more effective than either behavioural or environmental interventions delivered on their own.

  2. Interventions are equally effective on differing severities of visual impairment.

  3. Interventions are equally effective with fallers as they are with the general older population (inclusion criteria at point of recruitment into the study).

Characteristics of studies

Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion
  1. a

    RCT: randomised controlled trial

Balliet 1985Although an RCT, not a behavioural/environmental intervention (visual field training) and no physical activity outcome measures.
Campbell 2005bAlthough an RCT, aim of intervention was not to decrease physical activity limitation and no physical activity outcome measures. Falls as secondary outcome measure. La Grow 2006 is an article about implementing this RCT.
Cheung 2008Although an RCT, aim of intervention was not to decrease physical activity limitation and no physical activity outcome measures. Balance measures assessed. Although one aim was to increase confidence in safe ambulation this was not assessed.
Conrod 1986Although an RCT, not a behavioural/environmental intervention (residual vision training) and no physical activity outcome measures.
Cumming 2007Although an RCT, aim of intervention was not to decrease physical activity limitation and no physical activity outcome measures. Falls as secondary outcome measure. Most had change in glasses, with only a few having an occupational therapy Intervention.
Dahlin-Ivanoff 2002Although an RCT, outcome measure was perceived security in the performance of daily occupations rather than a subjective or objective measure of physical activity or change in physical activity.
Day 2002Although an RCT, aim of intervention was not to decrease physical activity limitation and no physical activity outcome measures. Falls as secondary outcome measure.
Deremeik 2007Although an RCT, aim of intervention was not to decrease physical activity limitation and no physical activity outcome measures. Outcomes were rehabilitation goals and visual correction. Residents were based in a nursing home.
Eklund 2007Although an RCT, aim of intervention was changing associations between assistive living devices and ADL dependence. No physical activity outcome measures.
Eklund 2008Although an RCT, aim of intervention was ADL dependence and self-reported health problems. No physical activity outcome measures.
Engel 2000Not an RCT or quasi-RCT. Physical activity outcomes not well reported and not validated.
Girdler 2010Although an RCT, aimed to increase participation in life situations but no physical activity outcome measures.
Gutman 2002Not an RCT or quasi-RCT and no physical activity outcome measures.
Kuyk 2008Not an RCT or quasi-RCT and no physical activity outcome measures.
Kuyk 2010Although an RCT, not a behavioural/environmental intervention (computerised vision training) and no physical activity outcome measures.
La Grow 2004Not an RCT or quasi-RCT and no physical activity outcome measures.
McCabe 2000Not an RCT or quasi-RCT and no physical activity outcome measures.
Overbury 1996Although an RCT, not a behavioural/environmental intervention (perceptual learning training - paper-based) and no physical activity outcome measures.
Pankow 2004Although an RCT, aimed to improve wellbeing. No physical activity outcome measures.
Reeves 2004Although an RCT, aimed to improve quality of life. No physical activity outcome measures.
Rumrill 1999Although an RCT, not a behavioural/environmental intervention (skills at requesting accommodation from employers for employees so few older people) and no physical activity outcome measures.
Scanlan 2004Although an RCT, not a behavioural/environmental intervention (microscopes) to extend reading time) and no physical activity outcome measures.
Smith 2009Although an RCT, not a behavioural/environmental intervention (educational programme on self care, food preparation, home and financial management) and no physical activity outcome measures.
Stelmack 2005Abstract only. Protocol for an RCT study and no activity outcome measures. Relates to Stelmack 2008a; Stelmack 2008b and Stelmack 2008c.
Vukicevic 2009Although an RCT, not a behavioural/environmental intervention (eccentric viewing computerised training) and no physical activity outcome measures.
West 2004Abstract only. Protocol for an RCT study and no activity outcome measures. Contacted author. Residents are based in a nursing home.

Characteristics of ongoing studies [ordered by study ID]

ACTRN12607000399493

Trial name or titleA randomised controlled trial of a low vision self management programme on quality of life in people with low vision.
MethodsRandomised controlled trial Parallel
Participants

Age 55 years and older, male and female

Inclusion criteria: Participants are clients of Vision Australia centres who have received a low vision assessment within the last 12 months and meet the following inclusion criteria:

i. visual acuity of < 6/12 and > 6/480 in the better eye with habitual correction;

ii. age 55 years or older;

iii. living independently (not in a nursing home);

iv. English-speaking;

v. no cognitive impairment as assessed by the six-item cognitive impairment test (Brooke & Bullock, 1999);

vi. adequate hearing to respond to normal conversation.

Exclusion criteria: Nil

InterventionsParticipants are randomised to receive either the new low vision self-management programme 'Living with Low Vision' or continued access to usual low vision rehabilitation services.

The 'Living with Low Vision' programme has been developed specifically for this study. It consists of eight 3-hour weekly facilitated group sessions. The programme is structured and a facilitator manual clearly outlines the content and delivery. As well as providing information, the topics in the programme are covered by exploring participants' experiences, difficulties and solutions. Participants are encouraged to draw on their extensive life experience and coping mechanisms and to develop new skills and strategies and apply these new techniques in their daily life. Participants are given the option to bring a relative, friend or carer to the programme with them.
Outcomes

Primary:

The Impact of Vision Impairment Questionnaire (IVI) is used to assess the restriction of participation in daily activities in people with low vision (Lamoureux, Pallant, Pesudovs, Hassell, & Keeffe, 2006). The 28-item IVI has been extensively validated and has been shown to be sensitive to rehabilitation-induced changes in people with low vision.

The Depression Anxiety Stress Scale (DASS) is used to assess psychological wellbeing (Henry & Crawford, 2005; Lovibond & Lovibond, 2004). This is a 21-item self-report measure that provides three 7-item subscales of negative affect: depression, anxiety and stress.

Secondary:

Adaptation to Age-related Vision Loss Scale (AVL-12) is used to assess psychosocial adaptation to vision loss, including acceptance of limitations, attitudes towards rehabilitation and appropriate help from family and friends (Horowitz & Reinhardt, 2006).

The General Self-Efficacy Scale (GSES) is used to assess general self-efficacy (Jerusalem & Schwarzer, 1992).

The Health Education Impact Questionnaire (HEIQ) scales: 'Skill and technique acquisition' (five items) and 'Positive and active engagement in life' (five items) are used to determine the direct impact of the programme on strategies to manage low vision and engagement in life (Nolte, Elsworth, Sinclair, & Osborne, 2006).

The Positive and Negative Affect Schedule (PANAS) is used to assess the both positive and negative mood (Watson, Clark, & Tellegen, 1988).

Starting date1/03/2007
Contact informationJill Keefe
Notes 

NCT00545220

Trial name or titleProblem Solving Training and Low Vision Rehabilitation
MethodsRandomised controlled trial Parallel
Participants

Aged 19 and over (including older people), male and female.

Inclusion Criteria:

  • +19 yrs of age;

  • Underwent a low vision rehabilitation initial eye exam;

  • No more than 2 errors on cognitive on cognitive screening measure (SPBS);

  • Must have access to telephone;

  • No significant hearing problems;

  • No significant communication problems;

  • Speaks fluent English.

Exclusion Criteria: Nil

Interventions

Participants are randomised to:

Experimental Group - Behavioural: problem-solving training

Sham Comparator - Behavioural: Sham

OutcomesNo information
Starting dateOctober 2007
Contact informationLaura Dreer
Notes 

NCT00769015

Trial name or titleLow Vision Depression Prevention Trial for Age Related Macular Degeneration (VITAL)
MethodsRandomised,controlled clinical trial
Participants

Aged 65 years and older, male and female

Inclusion Criteria: bilateral AMD and subthreshold depressive symptoms. At least 1 vision goal that is important yet difficult to carry out.

Exclusion Criteria: healthy older people;

  • Uncontrolled glaucoma, diabetic retinopathy, corneal dystrophy, or cataracts for which surgery within six months is likely will be exclusionary conditions;

  • Current diagnosis of depression;

  • Cognitive impairment;

  • Life-threatening illness or any other health conditions that interfere with study activities;

  • Patients who have received low vision rehabilitation or home-based occupational therapy (OT) in the preceding 12 months will be excluded.

Interventions

Collaborative Low Vision Rehabilitation (LVR) (optometrist and home-based occupational therapist (OT)) or enhanced LVR (optometrist and home-based Supportive Therapy (ST)). In this study, usual care LVR is enhanced with ST, which is a standardised placebo psychological treatment that controls for attention.

In BA-LVR, a low vision OT will deliver Behavior Activation (BA), a psychological treatment to prevent depression. This will be administered in the context of the standard of low vision care for OTs as defined by the American Occupational Therapy Association (AOTA). The OTs will collaborate with low vision optometrists, who will deliver the standard of low vision care as defined by the American Optometric Association. The optometrists will evaluate remaining vision and magnification needs, prescribe optical devices, and provide the OTs with initial care plans. The OTs will subsequently meet with participants in their homes six times over 12 weeks to enhance device use, home modifications, and compensatory strategies.

OutcomesPrimary Outcome Measures: Depression
Secondary Outcome Measures: Vision Function and Quality of Life
Starting dateJune 2009
Contact information

Robin Casten

 

Notes 

UKCRN ID 10883

Trial name or titleVIP2UK: Preventing falls in older people with a visual impairment
MethodsPilot randomised controlled trial
Participants

Aged 75 years and over

  • Independent community-dwelling;

  • Able to walk around their own residence;

  • Cognitively able to participate in the programme;

  • Able to understand the study requirements.

Vision-related inclusion criteria:

  • Binocular visual acuity less than 0.6 LogMAR (Snellen equivalent 6/24), stratified into (i) 0.61.0 LogMAR (1.0 LogMar = Snellens 6/60), (ii) less than 1.0 LogMAR, and/or

  • Moderate visual field loss, defined as affecting more than 20% of the test location used in a binocular Estermann test, stratified into (i) those missing < 50% of the test locations, (ii) those missing > 50% of the test location.

InterventionsOccupational therapist delivering home safety assessment and modifications with the approval of visually-impaired older people. Occupational therapist delivering the Otago home exercise programme, with support of peer mentors (buddies) that provide additional home visits and telephone calls throughout the intervention.
OutcomesPhoneFITT physical activity questionnaire, quality of life.
Starting dateMay 2011
Contact informationH. Waterman
Notes 

Zijlstra 2009

Trial name or titleEvaluation of a standardised orientation and mobility training in older adults with low vision
MethodsRandomised controlled trial
ParticipantsOlder adults (55 yrs and older) with low vision living in the community
InterventionsStandardised Orientation and Mobility (O&M) Training versus Regular O&M Training (comparator).
Outcomes

Primary Outcomes: Activities of daily life (subscale of the Groningen Activity Restriction Scale (GARS)), Distance activities and mobility (subscales of the Visual Functioning Questionnaire (VFQ)).

Secondary Outcomes: activities index (Frenchay Activities Index (FAI)), social support interactions (Social Support List (SSL 12-I)), health-related quality of life (EuroQol 5D (EQ5D)), feelings of anxiety (anxiety subscale of the Hospital Anxiety and Depression Scale (HADS-A)), concerns about falling (falls efficacy scale international (FES-I))

Starting dateNov 2007
Contact informationG.I.J.M. Kempen
NotesInformation on the training delivered - http://www.ncbi.nlm.nih.gov/pubmed/22734105

Ancillary