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Research Article  |   May 2013
Occupational Therapy Interventions to Improve the Reading Ability of Older Adults With Low Vision: A Systematic Review
Author Affiliations
  • Stacy Smallfield, DrOT, OTR/L, is Associate Professor, Department of Occupational Therapy, University of South Dakota, 414 East Clark Street, Vermillion, SD 57069; Stacy.Smallfield@usd.edu
  • Kari Clem, MS, OTR/L, and Ashley Myers, MS, OTR/L, were Graduate Students, Department of Occupational Therapy, University of South Dakota, Vermillion, at the time of the review
Article Information
Evidence-Based Practice / Geriatrics/Productive Aging / Vision / Special Issue on Effectiveness of Occupational Therapy Interventions for Older Adults With Low Vision
Research Article   |   May 2013
Occupational Therapy Interventions to Improve the Reading Ability of Older Adults With Low Vision: A Systematic Review
American Journal of Occupational Therapy, May/June 2013, Vol. 67, 288-295. doi:10.5014/ajot.2013.004929
American Journal of Occupational Therapy, May/June 2013, Vol. 67, 288-295. doi:10.5014/ajot.2013.004929
Abstract

This systematic review of the literature examined available evidence regarding the effectiveness of occupational therapy interventions for improving the reading performance of older adults with low vision. We reviewed 32 studies and found strong evidence supporting low vision programs that included occupational therapy and moderately strong evidence supporting the use of electronic magnification. Moderate evidence supported the influence of illumination on reading ability. Limited evidence was found to support eccentric viewing training and optical magnification. More evidence of higher quality is needed to validate the effectiveness of optical magnifiers, text eccentric viewing, characteristic preferences, and line guides within optical magnification. Additionally, further research is needed to develop a standard low vision rehabilitation program. The results of this review support the need for occupational therapy to be included in low vision rehabilitation. The implications of the findings for occupational therapy practice, research, and education are discussed.

Occupational therapy’s role in low vision rehabilitation is to help clients adapt to vision loss and participate in meaningful occupations by providing compensatory strategies that take into account various client factors and environmental influences. Occupational therapy practitioners use a holistic approach to address the biopsychosocial factors of each client. The objective of this literature review was to identify, evaluate, and integrate the available evidence regarding the effectiveness of occupational therapy interventions to enable older adults with low vision to use low vision devices (LVDs) for reading. The review addressed the following focused question: What is the evidence for the effectiveness of providing interventions within the scope of occupational therapy practice to improve the ability to use optical, nonoptical, and electronic magnifying devices to complete the reading required for performance of occupations by older adults with low vision?
Background and Statement of the Problem
Low vision is defined as irreversible and medically uncorrectable visual impairments of varying degrees and etiologies that result in disability and decreased visual performance and thus interfere with daily function (U.S. Department of Health and Human Services, 2004). Low vision is recognized as an important and growing problem, particularly in the older adult population. According to a report by the National Eye Institute (2004), an estimated 2.4 million Americans older than age 40 have low vision. Taking into account the aging baby boomer generation, the number of people with low vision is projected to increase to an alarming 3.9 million by 2020 (Congdon et al., 2004).
Visual impairments decrease visual performance as a result of an abnormal visual field, reduced acuity, reduced contrast sensitivity, or other ocular dysfunction. Among the many detrimental effects low vision has on the ability to engage in daily occupations, reading impairments may be one of the most meaningful because reading is required for the performance of numerous activities of daily living (ADLs) and instrumental ADLs (IADLs). For example, telecommunication devices, personal computers, medication prescriptions, food labels, household cleaner labels, appliance dial markings, expiration dates, financial statements, clothing labels, recipes, and community signage all require the ability to read, demonstrating the extent to which reading impairments resulting from low vision can hinder daily function. In addition, considering that diabetic retinopathy is one of the leading causes of low vision, people with diabetes are especially vulnerable to complications resulting from difficulty in reading medication labels, numbered syringes, blood glucose meters, and insulin monitors. These examples offer only a glimpse of the numerous limitations that a person with low vision experiences on a daily basis.
LVDs are commonly prescribed for people with low vision to assist with activities that involve reading. LVDs can be categorized as optical devices, nonoptical devices, and electronic magnifying devices. Examples of optical devices include stand and handheld magnifiers; absorptive lenses; prescription spectacles with high-powered lenses; telescopic spectacles for tasks at near, middle, and far distances; and reversed telescopes or mirrors for visual field defects (Bowers, Cheong, & Lovie-Kitchin, 2007). Nonoptical devices and methods for treating low vision include adjustable lighting strategies, audio recordings, Braille, and large-print publications. Electronic magnifying devices include closed-circuit television systems (CCTVs) and character enlargement systems (Peterson, Wolffsohn, Rubinstein, & Lowe, 2003).
Occupational therapists are grounded in an understanding of human capacity and disability. This knowledge, combined with the experience and training occupational therapy practitioners receive in assistive technology and activity analysis, makes occupational therapy practitioners a natural fit in low vision rehabilitation. One specific role that occupational therapy practitioners fulfill in low vision rehabilitation is teaching and training clients in the proper use of LVDs and assisting clients with integrating LVDs into their daily routines (Copolillo & Teitelman, 2005). In other words, occupational therapy practitioners are able to assist in maximizing the reading ability of older adults with low vision through the use of assistive devices and other therapeutic adaptations.
Because of the expected increase in older adults with low vision, it is imperative to establish the effectiveness of occupational therapy interventions to solidify the profession’s place in low vision rehabilitation and to ensure the highest quality services for the current and future older adult population using research evidence. Therefore, the purpose of this systematic review was to examine existing evidence to determine the effectiveness of occupational therapy interventions in improving the reading required for performance of occupations by older adults with low vision through the use of optical, nonoptical, and electronic magnifying devices.
Method for Conducting the Evidence-Based Review
The methods of this study involved conducting a systematic review of the literature, which consists of analyzing and summarizing research information on a topic of interest to arrive at an unbiased conclusion regarding a focus question (Law & MacDermid, 2008). We completed this systematic review in collaboration with the American Occupational Therapy Association (AOTA) as part of an evidence-based literature review project focusing on older adults with low vision. An in-depth description of the methodology used in this systematic review can be found in further detail in the article “Methodology for the Systematic Reviews on Occupational Therapy Interventions for Older Adults With Low Vision” in this issue (Arbesman, Lieberman, & Berlanstein, 2013). Supplemental Table 1 summarizes selected studies on interventions that address the reading ability of older adults with low vision (available online at http://ajot.aotapress.net; navigate to this article, and click on “Supplemental Materials”).
Results
We reviewed 268 article abstracts retrieved from the Medline, Cochrane, PsycINFO, Ageline, and CINAHL databases and abstracts found in hand searches of journals and reference lists for potential inclusion in this review. After title and abstract review of these articles, 76 were retained for further evaluation. We retrieved the full text of these articles, and the three of us analyzed them individually and then collaboratively. We kept 32 studies for inclusion in this systematic review; 16 provided Level I evidence, 8 provided Level II evidence, and 8 provided Level III evidence. We synthesized the content of these studies into themes and subthemes consistent with the objectives of each study.
We determined an overall strength of evidence for each theme and subtheme on the basis of the number of articles supporting the findings in each theme and the level of evidence of each article. Consistent results in 2 or more Level I studies were rated as strong evidence, whereas consistent results in 1 Level I study plus more than 2 lower level studies were rated as moderate evidence (U.S. Preventive Services Task Force [USPSTF], 2008; Verhagen et al., 2007). One Level I study or consistent results in multiple lower level studies were rated as limited evidence (USPSTF, 2008; Verhagen et al., 2007). Finally, inconsistent results between studies were rated as conflicting evidence.
Effectiveness of Low Vision Devices
Five studies included in this systematic review examined the effectiveness of an LVD in improving reading performance supplying Level II and Level III evidence (Bowers, Lovie-Kitchin, & Woods, 2001; Cheong, Lovie-Kitchin, Bowers, & Brown, 2005; Horowitz, Brennan, Reinhardt, & MacMillan, 2006; Margrain, 2000; Nguyen, Weismann, & Trauzettel-Klosinski, 2009). The types of LVDs studied consisted of high-add spectacles, nonilluminated and illuminated handheld magnifiers, nonilluminated and illuminated stand magnifiers, high-plus lenses, telescopes, and electronic magnifiers such as CCTVs.
Margrain (2000)  and Nguyen et al. (2009)  compared participants’ ability to read before and after the introduction of LVDs. Both research groups found a significant difference in the number of participants able to read with versus without a device. Horowitz et al. (2006)  found that the use of optical devices decreased the level of disability when performing ADL tasks. Finally, Bowers, Lovie-Kitchin, and Wood (2001)  and Cheong et al. (2005)  studied the difference between reading at critical print size with and without an optical magnifier and found that the use of a magnifier did not produce slower reading speeds, as expected, than reading at critical print size with no device.
Although all 5 of these studies found that LVDs either improved reading speed or decreased the level of disability in performing IADLs, in combination they provide limited evidence to support the effectiveness of LVDs over no device use because the research designs lacked control groups and randomization. Therefore, we conclude that more evidence of higher methodological quality is needed to determine the impact of LVDs on reading performance.
Comparison of Optical and Electronic Magnifying Devices
Five studies included in this review compared the effectiveness of optical and electronic magnifying devices in improving reading performance (Culham, Chabra, & Rubin, 2004; Goodrich & Kirby, 2001; Goodrich, Kirby, Wagstaff, Oros, & McDevitt, 2004; Peterson et al., 2003; Stelmack, Reda, Ahlers, Bainbridge, & McCray, 1991). Two provided Level I evidence and 3 provided Level II evidence. The types of LVDs studied included handheld, stand-based, mouse-based, and head-mounted electronic magnification systems (also known as CCTVs; Culham et al., 2004; Goodrich & Kirby, 2001; Goodrich et al., 2004; Stelmack et al., 1991); spectacle reading glasses (Culham et al., 2004; Stelmack et al., 1991); illuminated stand magnifiers (Stelmack et al., 1991); and the Nomad (MicroVision, Redmond, WA), an augmented vision system that projects an image directly onto the retina using a laser (Goodrich et al., 2004).
Each research group studied different combinations of optical and electronic devices. Four groups concluded that use of stand-based electronic magnification systems produced faster reading rates (Goodrich & Kirby, 2001; Goodrich et al., 2004; Peterson et al., 2003; Stelmack et al., 1991) and longer reading duration (Goodrich & Kirby, 2001; Goodrich et al., 2004; Stelmack et al., 1991) compared with other devices. Therefore, we conclude that moderately strong evidence supports the use of stand-based electronic magnification systems. One study found limited evidence that handheld electronic magnification is more beneficial than a prescribed optical device for reading purposes (Goodrich & Kirby, 2001). Additionally, 2 studies (Culham et al., 2004; Stelmack et al., 1991) found conflicting results regarding the effectiveness of spectacle reading glasses. Moreover, a Level II study (Culham et al., 2004) found that head-mounted electronic magnification systems are less effective than optical magnifiers for maximizing reading speed.
Effectiveness of Low Vision Rehabilitation Programs That Include Occupational Therapy
Five studies investigated the effectiveness of low vision rehabilitation programs that included occupational therapy in improving reading performance required for the performance of daily occupations (Eklund & Dahlin-Ivanoff, 2007; Eklund, Sjöstrand, & Dahlin-Ivanoff, 2008; Markowitz, Kent, Schuchard, & Fletcher, 2008; McCabe, Nason, Demers Turco, Friedman, & Seddon, 2000; Pankow, Luchins, Studebaker, & Chettleburgh, 2004). Four of these studies provided Level I evidence, and 1 provided Level III evidence. These studies specifically recognized occupational therapy as a valuable component of low vision rehabilitation. Occupational therapists provided a combination of the following services:
Other health professionals included in the programs studied included ophthalmologists, opticians, low vision therapists, and lighting experts.
These studies produced strong evidence substantiating the benefits of low vision programs that involve occupational therapy. Benefits of these programs identified by the authors included increased speed and accuracy in spot reading, short-term reading, identification of paper currency, and clock reading (McCabe et al., 2000); decreased dependence in ADL performance (Eklund & Dahlin-Ivanoff, 2007; Eklund et al., 2008; McCabe et al., 2000; Pankow et al., 2004); improvements in the ability to read medication labels (Markowitz et al., 2008); and improvements in the ability to perform occupations over a 28-mo period (Eklund et al., 2008). These studies strongly suggest the importance of including occupational therapy in low vision rehabilitation programs.
Effectiveness of Low Vision Rehabilitation Programs That Do Not Include Occupational Therapy
Five studies investigated the effectiveness of low vision rehabilitation programs that did not include occupational therapy but contained components within the occupational therapy scope of practice (Goodrich, Kirby, Wood, & Peters, 2006; La Grow, 2004; Reeves, Harper, & Russell, 2004; Scanlan & Cuddeford, 2004; Stelmack et al., 2008). These comprehensive programs typically consisted of a combination of services that might include a low vision examination, diagnosis and prognosis of the eye condition, education regarding the condition, low vision therapy, prescription of an LVD, eccentric viewing, and home visits. Three studies provided Level I evidence, 1 provided Level II evidence, and 1 provided Level III evidence. The studies found conflicting evidence regarding the effectiveness of low vision rehabilitation programs in improving performance in reading or activities that involved reading when compared with an alternate intervention (Goodrich et al., 2006; La Grow, 2004; Reeves et al., 2004; Scanlan & Cuddeford, 2004). Examples of alternate interventions included additional home visits (Reeves et al., 2004), a shorter educational session (Scanlan & Cuddeford, 2004), or use of existing community low vision services (La Grow, 2004). Moreover, limited evidence was found supporting the effectiveness of these programs when compared with receiving no intervention (Stelmack et al., 2008).
Effectiveness of Nonoptical Devices
Illumination.
Five studies, 3 providing Level I evidence and 2 providing Level II evidence, focused on the effectiveness of illumination as a means of improving older adults’ ability to read (Bowers, Meek, & Stewart, 2001; Eldred, 1992; Eperjesi, Maiz-Fernandez, & Bartlett, 2007; Fosse & Valberg, 2004; Haymes & Lee, 2006). Although the studies provided moderate evidence to support the influence of illumination on reading speed (Bowers, Meek, & Stewart, 2001; Eldred, 1992), no evidence was found to support a particular type of light source (Eperjesi et al., 2007; Haymes & Lee, 2006). In general, older adults with low vision typically require illumination levels of 1,000 to 7,000 lux (typical room lighting is 500–600 lux, and home lighting is typically 50 lux) to optimally perform reading activities (Bowers, Meek, & Stewart, 2001; Eldred, 1992), but they often prefer lower-than-optimal illumination levels. Therefore, because each client’s vision is unique, optimal illumination levels should be determined individually for each client (Eldred, 1992; Fosse & Valberg, 2004).
Text Characteristics.
A systematic review of the literature (Russell-Minda et al., 2007) gathered available evidence concerning the attributes of typefaces and their impact on text legibility. This systematic review included 18 studies, most of which provided Level II evidence and none of which were randomized controlled trials. The study found inconclusive evidence regarding the effects of serif or sans serif typefaces on the legibility of print. However, participants with low vision included in these studies appeared to have a subjective preference for sans serif over serif fonts. The researchers concluded that typefaces such as Arial, Veranda, Helvetica, and Adsans are more readable than Times New Roman and that font size should be at least 16 to 18 points. They also concluded that adequate spacing between letters provides an advantage to people with low vision.
Viewing Techniques.
Four studies examined the effects of training in specialized viewing techniques, including eccentric viewing and binocular or monocular viewing, on the reading performance of older adults with age-related macular degeneration (AMD; Frennesson, Jakobsson, & Nilsson, 1995; Kabanarou & Rubin, 2006; Vukicevic & Fitzmaurice, 2005, 2009). Two studies provided Level I evidence, 1 provided Level II evidence, and 1 provided Level III evidence. These studies found limited evidence supporting eccentric viewing completed with specific computer software programs for near vision and ADLs (Frennesson et al., 1995; Vukicevic & Fitzmaurice, 2005, 2009). In addition, limited evidence supported eccentric viewing in combination with instruction in magnification (Vukicevic & Fitzmaurice, 2005). Kabanarou and Rubin (2006)  compared the effects of binocular versus monocular viewing and found no evidence in support of one technique over the other. Because of small sample sizes in several of these studies, higher quality research is needed to substantiate the implementation of eccentric viewing training and other viewing techniques for people with AMD and central scotomas.
Overlays.
Eperjesi, Fowler, and Evans (2004)  examined the effects of 10 colored light-filtered overlays on the reading rate of people with AMD in a Level I study. They found no significant relationship between the colors of the filters and reading rate. The study found no evidence supporting the use of a colored overlay to improve reading for the performance of daily occupations by older adults with low vision.
Large-Print Reading Home Program.
In a study that provided Level II evidence, Cheong et al. (2005)  examined whether using large-print reading material at home with and without a reduced field of view, in addition to brief in-office practice sessions, improved reading performance. The results provided no support for the use of a large-print reading home program before learning how to use an optical magnifier; no significant difference was found in reading rates between the three groups. This study was not adequately powered; the sample size was not large enough to yield generalizable findings.
Line Guide in an Optical Magnifier.
Cheong, Bowers, and Lovie-Kitchin (2009)  examined the effects of using a line guide with a stand magnifier on the reading performance of older adults with AMD in a Level III study. They found that use of a line guide resulted in a small decrease in reading speed. Despite this finding, 48% of participants preferred using it, reporting that it provided better orientation than reading with a stand magnifier without a line guide. The study’s design did not provide the quality of evidence needed to support or refute the effectiveness of using a line guide within an optical magnifier during reading tasks. Therefore, more research is needed in this area.
Discussion and Implications for Practice, Education, and Research
Implications for Practice
The results of this literature review support the role of occupational therapy in the field of low vision rehabilitation and provide evidence for the effectiveness of specific occupational therapy interventions. Specifically, we conclude that for clients whose goal is to improve reading performance, occupational therapy practitioners addressing low vision should include training in electronic magnification and adequate illumination needs. Including instruction in optical magnifiers and eccentric viewing may also be considered, although the evidence for these intervention strategies is limited. No or inconclusive evidence supports the use of overlays, a particular type of light source, or a particular type of font in maximizing reading performance.
Practitioners should consider these results while keeping in mind that every client with low vision has unique preferences in terms of the various components of low vision rehabilitation, such as levels of illumination and preferred LVDs. For example, stand-based electronic systems are not ideal for some reading activities, and not all older adults have the financial capacity to obtain electronic magnification systems. Therefore, prescribed optical devices may be a suitable alternative to electronic magnification in some cases (Peterson et al., 2003; Stelmack et al., 1991). Practitioners must take into account the needs of individual clients in terms of the reading tasks they wish to perform, the natural environment in which they perform these tasks, and their financial situation. By applying a holistic approach in practice, practitioners can remain client centered and ultimately determine the most appropriate interventions to meet each client’s unique needs.
Implications for Education
All health care professionals are expected to validate practice with evidence. This systematic review contributes valuable evidence for occupational therapy practitioners regarding available and favorable options for electronic and optical magnification as well as nonoptical strategies for reading performance. Practitioners can use this information to educate themselves, their colleagues, and their clients on which devices, programs, and interventions have proved to be most beneficial. In addition, the results of this review can be incorporated into occupational therapy educational programs to educate students on the various components of low vision rehabilitation, the role of occupational therapy in low vision rehabilitation, and the unique needs of the older adult population with low vision.
Implications for Research
The findings of this literature review contribute valuable evidence to the existing body of research in the area of occupational therapy interventions in low vision rehabilitation. Evidence was limited in several areas, however, suggesting the need for further research that generates higher levels of evidence, perhaps by including larger sample sizes and a variety of low vision diagnoses. Specifically, additional research is necessary to determine the effectiveness of optical magnifiers, eccentric viewing training, preferred retinal locus training, text characteristic preferences, and line guides within optical magnification and to assist in the development of a standard low vision program.
Future research must also incorporate the promotion of functional health literacy in older adults, defined as their ability to gather, interpret, and use information to make suitable health-related decisions (AOTA, 2011). Occupational therapy practitioners must consider clients’ functional health literacy level when providing low vision rehabilitation services to maximize clients’ understanding and incorporation of practitioners’ skilled recommendations into their daily lives. Additionally, because low vision in the older adult population often occurs with other comorbidities, such as depression, cognitive decline, hearing loss, and physical limitations from a variety of conditions (Perlmutter, Bhorade, Gordon, Hollingsworth, & Baum, 2010), future research needs to consider how people with multiple health limitations can successfully manage their health and continue to participate in meaningful occupations. It is crucial for future research to address these considerations because such research remains the gateway to the ongoing delivery of progressive treatment interventions to clients with low vision.
Limitations
Several limitations of this systematic review must be considered when interpreting the results. Nine of the 32 studies had sample sizes of fewer than 20 participants per group, which may not have been large enough to validate the results. Several studies were limited by homogeneous samples; 17 studies included only participants with AMD, and the results of these studies cannot be generalized to the entire low vision population. Some interventions were supported by only one or a few studies of low methodological quality. Variations exist across the studies in terms of research interventions, low vision rehabilitation programs, and outcome measures, making it difficult to directly compare the results between studies. Additionally, outcome measures used in the studies may not have possessed the sensitivity, validity, and reliability to determine accurate results. Finally, 4 studies measured performance of daily tasks, some of which required reading for completion. However, the authors did not report the individual results of each of the various tasks that were assessed, but rather reported functional performance as a whole; therefore, we can only assume that the tasks involving reading improved along with those that did not.
Conclusion
Although more research is necessary, it can be concluded from this systematic review of the literature that interventions within the scope of occupational therapy improve the ability of older adults with low vision to complete the reading required for performance of occupations. Specifically, this review found strong evidence validating low vision programs that include occupational therapy, moderately strong evidence substantiating the benefits of electronic magnification, moderate evidence regarding the influence of illumination levels on reading performance, and limited evidence for eccentric viewing training and optical magnification. Therefore, when included as part of an interdisciplinary approach to low vision rehabilitation, occupational therapy can make measurable differences in the lives of older adults living with low vision.
Acknowledgment
We acknowledge the guidance received from Deborah Lieberman, Marion Arbesman, Jennifer Kaldenberg, and Sue Berger during the review process and manuscript preparation. This article is based on a paper presented on April 15, 2011, at AOTA’s 91st Annual Conference & Expo, Philadelphia.
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*Indicates studies that were systematically reviewed for this article.
Indicates studies that were systematically reviewed for this article.×
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