By Jamie Grant - Occupational Therapist; Director, The Occupational Therapy Hub
'Terry' had a stroke originating in his left cerebral hemisphere. At the age of 40, he became a relatively young service user on our caseload. He experienced very little motor and cognitive deficit, but was significantly affected by dysarthria - difficulty speaking caused by brain damage (NHS 2019). His quality of life was also impacted by fatigue and hemianopia - partial blindness or a loss of sight in half of your visual field (Healthline, 2019). Prior to hospital admission, Terry had been working, enjoyed family time and played golf to a high standard. I visited him and his wife at their home, where I observed the extent of his symptoms. His frustration with slurred speech and impaired sight (loss of right visual field) was clear to see, made worse by the uncertainty of his prognosis and the lack of structure to his week, due to being off work.
'It can be argued that vision is the major sensory input into the human brain, by virtue of the fact that about half of all afferent fibres projecting to the brain are from the eye and by the sophistication of the neural systems controlling visual processing. Brain damage disrupts these complicated processes, resulting in severe visual impairments including hemianopia. Patients with hemianopia complain mainly of difficulties with reading and scanning scenes fast enough to make sense of things as a whole.' (Pambakian and Kennard, 1997)
Terry was referred to the speech and language therapist, to work on his dysarthria. I explored elements of grading and pacing that he could adopt, in order to address the fatigue he was currently experiencing. This included pacing mobility around his large two-storey house and simple adaptive approaches, such as placing chairs at suitable points, to rest.
As part of my intervention, I researched and introduced University College London (UCL’s) Read-Right to Terry. This is an online programme to work on reading speed; he found the visual field loss affected this occupation. My team also suggested Terry purchase a white stick, to act as a prompt to the public. He had discussed a stressful experience at a train station, when people passed him at very close range and he was only able realise their presence at short notice.
Post-discharge from the stroke team's support, I called Terry to discuss his recovery and recent ophthalmology appointment. Due to the dysarthria, his wife currently answers his phone. She informed me that consultants had confirmed his hemianopia diagnosis, that he is now certified as ‘sight impaired’ and that he is unlikely to be able to drive again. He has been recommended to contact a charity for the blind, to discuss benefit entitlement - and to contact his workplace occupational health department, to discuss what he is still able to do professionally. He now uses golf as rehabilitation, to improve his balance and stamina.
The experience of working with Terry was emotive. He was young to have had a stroke and previously active in many occupations. I also gained clear insight into how it was affecting his wife and their relationship.
It was difficult to see Terry come to terms with the long-term impact of hemianopia on his quality of life. I understood that, with regards to occupational therapy in this service, there was limited rehab potential for his loss of vision. Longer-term, he could adapt his routines, but his occupational potential had been reduced and he would not be able to drive again. On the other hand, I believe my Read-Right intervention was of use to Terry. It provided him a focus and offers long-term improvement to his reading processing speed. He also values the use of the white stick, putting aside the stigma attached to it. Terry's wife was appreciative of the follow-up call, including my agreement to contact the physiotherapist in our team, to provide advice regarding continuing neck pain. Multidisciplinary working has been demonstrated well throughout our intervention with Terry. However, due to only a few scheduled visits, I was unable to provide more signposting input, or further assessment of his reading speed. I would also have liked to join him on a visit to his golf club, to provide support for this meaningful occupation of his.
Despite the inability to restore Terry’s visual field, a condition of this nature presents opportunities to work broadly - from leisure activity and vocational support, to dealing with the emotional impact and signposting to charities and other specialist supportive organisations.
I have taken from this experience the realisation that, unlike with most service users I have supported to-date, there can exist a ceiling to occupational therapy rehabilitation. The fight in timetabling a large caseload also conflicted with intervention potential for Terry - although the time allocated to him was used efficiently and effectively. In future, if session allocation was flexible, I would commit greater therapy input to a service user affected by stroke in this way.
Originally written in 2016. Setting: A community stroke discharge service in the UK.
For more information on UCL's Read-Right programme, visit their website.
Healthline (2019) Hemianopia. Available from: https://www.healthline.com/health/hemianopia [Accessed 26 July 2019].
NHS (2019) Dysarthria (difficulty speaking). Available from: https://www.nhs.uk/conditions/dysarthria/ [Accessed 26 July 2019].
Pambakian, A.L.M. and Kennard, C. (1997) Can visual function be restored in patients with homonymous hemianopia? British Journal of Ophthalmology [online]. 81 (4), pp. 324-328. [Accessed 26 July 2019].