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1.  Longitudinal observation, evaluation and interpretation of coping with mental (emotional) health in low vision rehabilitation using the Dutch ICF Activity Inventory 
Since there is evidence that mental health aspects (such as depression) may inhibit an optimal rehabilitation outcome, there is growing interest in the psychosocial aspects of vision loss as part of rehabilitation. The purpose of this study is to provide more insight into the construct validity and (longitudinal) interpretation of goals related to ‘Coping with mental (emotional) health aspects’ which are part of the recently developed ‘Dutch ICF Activity Inventory (D-AI). Moreover, the data allowed to provide some insight in the outcome in this domain in relation to rehabilitation programs followed in Dutch Multidisciplinary Rehabilitation Centers at baseline and follow-up.
In a cohort of 241 visually impaired persons, the D-AI was assessed at baseline (enrollment), 4 and 12 months, The importance and difficulty of the D-AI goals ‘Handle feelings’, ‘Acceptance’, and ‘Feeling fit’ and difficulty scores of underlying tasks were further analyzed, together with similar or related standardized questionnaires. At baseline, Spearman correlations were determined between D-AI goals and task and additional questionnaires to investigate the construct validity. Corrected and uncorrected linear mixed models were used to determine longitudinal rehabilitation outcomes in relation to rehabilitation programs followed.
Baseline correlations indicated that the difficulty of tasks and the umbrella goal ‘Acceptance’ were not similar. Longitudinal analyses provided insight in some subtle differences in concepts measured at the goal and task level of the D-AI, as well as similar validated questionnaires. After correcting for confounding variables, none of the underlying task difficulty scales changed over time. For goal difficulty scores only ‘Acceptance’ was reported to be significantly less difficult at 4 and 12 months follow-up. Importance scores of goals were stable from baseline to follow-up.
With respect to the constructs measured, results support the formulation of the new goal question ‘Emotional life’ which replaces the goals ‘Handle feelings’ and ‘Acceptance’. Results indicate that MRCs should pay more attention to problems related to mental health. They have started to use the D-AI as it seems a promising tool to investigate and evaluate rehabilitation needs (including those related to mental health) over time and to clearly define rehabilitation goals from the very start.
PMCID: PMC4308065  PMID: 25539603
Low vision; Rehabilitation; D-AI; ICF; Activities and participation; Patient-centered; Mental health; Acceptance; Fatigue; Handle feelings
2.  Dual sensory loss: development of a dual sensory loss protocol and design of a randomized controlled trial 
BMC Geriatrics  2013;13:84.
Dual sensory loss (DSL) has a negative impact on health and wellbeing and its prevalence is expected to increase due to demographic aging. However, specialized care or rehabilitation programs for DSL are scarce. Until now, low vision rehabilitation does not sufficiently target concurrent impairments in vision and hearing. This study aims to 1) develop a DSL protocol (for occupational therapists working in low vision rehabilitation) which focuses on optimal use of the senses and teaches DSL patients and their communication partners to use effective communication strategies, and 2) describe the multicenter parallel randomized controlled trial (RCT) designed to test the effectiveness and cost-effectiveness of the DSL protocol.
To develop a DSL protocol, literature was reviewed and content was discussed with professionals in eye/ear care (interviews/focus groups) and DSL patients (interviews). A pilot study was conducted to test and confirm the DSL protocol. In addition, a two-armed international multi-center RCT will evaluate the effectiveness and cost-effectiveness of the DSL protocol compared to waiting list controls, in 124 patients in low vision rehabilitation centers in the Netherlands and Belgium.
This study provides a treatment protocol for rehabilitation of DSL within low vision rehabilitation, which aims to be a valuable addition to the general low vision rehabilitation care.
Trial registration
Netherlands Trial Register (NTR) identifier: NTR2843
PMCID: PMC3751532  PMID: 23941667
Dual sensory loss; Visual impairment; Hearing loss; Elderly; Low vision rehabilitation; Hearing aids; Communication; Intervention; RCT
3.  Stepped-care to prevent depression and anxiety in visually impaired older adults – design of a randomised controlled trial 
BMC Psychiatry  2013;13:209.
Subthreshold depression and anxiety are common in the growing population of visually impaired older adults and increase the risk of full-blown depressive or anxiety disorders. Adequate treatment may prevent the development of depression or anxiety in this high risk group.
A stepped-care programme was developed based on other effective interventions and focus groups with professionals and patient representatives of three low vision rehabilitation organisations in the Netherlands and Belgium. The final programme consists of four steps: 1) watchful waiting, 2) guided self-help, 3) problem solving treatment, 4) referral to general practitioner. The (cost-)effectiveness of this programme is evaluated in a randomised controlled trial. Patients (N = 230) are randomly assigned to either a treatment group (stepped-care) or a control group (usual care). The primary outcome is the incidence of depressive and anxiety disorders, measured with the Mini International Neuropsychiatric Interview (MINI).
Preventive interventions for depression and anxiety have received little attention in the field of low vision. A stepped-care programme that focuses on both depression and anxiety has never been investigated in visually impaired older adults before. If the intervention is shown to be effective, this study will result in an evidence based treatment programme to prevent depression or anxiety in patients from low vision rehabilitation organisations. The pragmatic design of the study greatly enhances the generalisability of the results. However, a possible limitation is the difficulty to investigate the contribution of each individual step.
Trial registration
Identifier: NTR3296
PMCID: PMC3751101  PMID: 23937975
Low vision; Stepped-care; Older adults; Depression; Anxiety; Prevention
4.  A systematic review on ‘Foveal Crowding’ in visually impaired children and perceptual learning as a method to reduce Crowding 
BMC Ophthalmology  2012;12:27.
This systematic review gives an overview of foveal crowding (the inability to recognize objects due to surrounding nearby contours in foveal vision) and possible interventions. Foveal crowding can have a major effect on reading rate and deciphering small pieces of information from busy visual scenes. Three specific groups experience more foveal crowding than adults with normal vision (NV): 1) children with NV, 2) visually impaired (VI) children and adults and 3) children with cerebral visual impairment (CVI). The extent and magnitude of foveal crowding as well as interventions aimed at reducing crowding were investigated in this review. The twofold goal of this review is : [A] to compare foveal crowding in children with NV, VI children and adults and CVI children and [B] to compare interventions to reduce crowding.
Three electronic databases were used to conduct the literature search: PubMed, PsycINFO (Ovid), and Cochrane. Additional studies were identified by contacting experts. Search terms included visual perception, contour interaction, crowding, crowded, and contour interactions.
Children with normal vision show an extent of contour interaction over an area 1.5–3× as large as that seen in adults NV. The magnitude of contour interaction normally ranges between 1–2 lines on an acuity chart and this magnitude is even larger when stimuli are arranged in a circular configuration. Adults with congenital nystagmus (CN) show interaction areas that are 2× larger than those seen adults with NV. The magnitude of the crowding effect is also 2× as large in individuals with CN as in individuals with NV. Finally, children with CVI experience a magnitude of the crowding effect that is 3× the size of that experienced by adults with NV.
The methodological heterogeneity, the diversity in paradigms used to measure crowding, made it impossible to conduct a meta-analysis. This is the first systematic review to compare crowding ratios and it shows that charts with 50% interoptotype spacing were most sensitive to capture crowding effects. The groups that showed the largest crowding effects were individuals with CN, VI adults with central scotomas and children with CVI. Perceptual Learning seems to be a promising technique to reduce excessive foveal crowding effects.
PMCID: PMC3416571  PMID: 22824242
5.  Usefulness and acceptability of a standardised orientation and mobility training for partially-sighted older adults using an identification cane 
Orientation and mobility (O&M) training in using an identification (ID) cane is provided to partially-sighted older adults to facilitate independent functioning and participation in the community. Recently, a protocolised standardised O&M-training in the use of the ID cane was developed in The Netherlands. The purpose of this study is to assess the usefulness and acceptability of both the standardised training and the regular training for participants and O&M-trainers in a randomised controlled trial (NCT00946062).
The standardised O&M-training consists of two structured face-to-face sessions and one telephone follow-up, in which, in addition to the regular training, self-management and behavioural change techniques are applied. Questionnaires and interviews were used to collect data on the training’s usefulness, e.g. the population reached, self-reported benefits or achievements, and acceptability, e.g. the performance of the intervention according to protocol and participants’ exposure to and engagement in the training.
Data was collected from 29 O&M-trainers and 68 participants. Regarding the self-reported benefits, outcomes were comparable for the standardised training and the regular training according the trainers and participants e.g., about 85% of the participants in both groups experienced benefits of the cane and about 70% gained confidence in their capabilities. Participants were actively involved in the standardised training. Nearly 40% of the participants in the standardised training group was not exposed to the training according to protocol regarding the number of sessions scheduled and several intervention elements, such as action planning and contracting.
The standardised and regular O&M-training showed to be useful and mostly acceptable for the partially-sighted older adults and trainers. Yet, a concern is the deviation from the protocol of the standardised O&M-training by the O&M-trainers regarding distinguishing elements such as action planning. Overall, participants appreciated both trainings and reported benefit.
PMCID: PMC3439402  PMID: 22681932
Low vision; Aged; Mobility limitation; Canes; Process assessment
6.  The impact of low vision on activities of daily living, symptoms of depression, feelings of anxiety and social support in community-living older adults seeking vision rehabilitation services 
Quality of Life Research  2011;21(8):1405-1411.
Previous studies showed that older persons with vision loss generally reported low levels of health-related quality of life, although study outcomes with respect to feelings of anxiety and social support were inconsistent. The objective of this study was to examine the impact of low vision on health-related quality of life, including feelings of anxiety and social support, among community-living older adults seeking vision rehabilitation services.
Differences of activities of daily living (Groningen Activity Restriction Scale—GARS), symptoms of depression and feelings of anxiety (Hospital Anxiety and Depression Scales—HADS) and social support (Social Support Scale Interactions—SSL12-I) between 148 older persons ≥57 years with low vision and a reference population (N = 4,792) including eight patient groups with different chronic conditions were tested with Student’s t tests.
Older persons with vision loss reported poorer levels of functioning with respect to activities of daily living, symptoms of depression and feelings of anxiety as compared to the general older population as well as compared to older patients with different chronic conditions. In contrast, older persons with vision loss reported higher levels of social support.
Vision loss has a substantial impact on activities of daily living, symptoms of depression and feelings of anxiety. Professionals working at vision rehabilitation services may improve their quality of care as they take such information into account in their intervention work.
PMCID: PMC3438403  PMID: 22090173
Low vision; Aged; Quality of life; Chronic disease; Activities of daily living; Mental health; Social support
7.  Re-evaluating a vision-related quality of life questionnaire with item response theory (IRT) and differential item functioning (DIF) analyses 
For the Low Vision Quality Of Life questionnaire (LVQOL) it is unknown whether the psychometric properties are satisfactory when an item response theory (IRT) perspective is considered. This study evaluates some essential psychometric properties of the LVQOL questionnaire in an IRT model, and investigates differential item functioning (DIF).
Cross-sectional data were used from an observational study among visually-impaired patients (n = 296). Calibration was performed for every dimension of the LVQOL in the graded response model. Item goodness-of-fit was assessed with the S-X2-test. DIF was assessed on relevant background variables (i.e. age, gender, visual acuity, eye condition, rehabilitation type and administration type) with likelihood-ratio tests for DIF. The magnitude of DIF was interpreted by assessing the largest difference in expected scores between subgroups. Measurement precision was assessed by presenting test information curves; reliability with the index of subject separation.
All items of the LVQOL dimensions fitted the model. There was significant DIF on several items. For two items the maximum difference between expected scores exceeded one point, and DIF was found on multiple relevant background variables. Item 1 'Vision in general' from the "Adjustment" dimension and item 24 'Using tools' from the "Reading and fine work" dimension were removed. Test information was highest for the "Reading and fine work" dimension. Indices for subject separation ranged from 0.83 to 0.94.
The items of the LVQOL showed satisfactory item fit to the graded response model; however, two items were removed because of DIF. The adapted LVQOL with 21 items is DIF-free and therefore seems highly appropriate for use in heterogeneous populations of visually impaired patients.
PMCID: PMC3201037  PMID: 21888648
Visual impairment; Vision-related quality of life; Item response theory; Graded response model; Differential item functioning
8.  Feasibility of the Dutch ICF Activity Inventory: a pilot study 
Demographic ageing will lead to increasing pressure on visual rehabilitation services, which need to be efficiently organised in the near future. The Dutch ICF Activity Inventory (D-AI) was developed to assess the rehabilitation needs of visually impaired persons. This pilot study tests the feasibility of the D-AI using a computer-assisted telephone interview.
In addition to the regular intake, the first version of the D-AI was assessed in 20 patients. Subsequently, patients and intake assessors were asked to fill in an evaluation form. Based on these evaluations, a new version of the D-AI was developed.
Mean administration time of the D-AI was 88.8 (± 41.0) minutes. Overall, patients and assessors were positive about the D-AI assessment. However, professionals and 60% of the patients found the administration time to be too long. All included items were considered relevant and only minor adjustments were recommended.
The systematic character of the revised D-AI will prevent topics from being overlooked and indicate which needs have the highest priority from a patient-centred perspective. Moreover, ongoing assessment of the D-AI will enhance evaluation of the rehabilitation process. To decrease administration time, in the revised D-AI only the top priority goals will be fully assessed. Using the D-AI, a rehabilitation plan based on individual needs can be developed for each patient. Moreover, it enables better evaluation of the effects of rehabilitation. A larger validation study is planned.
PMCID: PMC3006382  PMID: 21110871
9.  Effects of standard training in the use of closed-circuit televisions in visually impaired adults: design of a training protocol and a randomized controlled trial 
Reading problems are frequently reported by visually impaired persons. A closed-circuit television (CCTV) can be helpful to maintain reading ability, however, it is difficult to learn how to use this device. In the Netherlands, an evidence-based rehabilitation program in the use of CCTVs was lacking. Therefore, a standard training protocol needed to be developed and tested in a randomized controlled trial (RCT) to provide an evidence-based training program in the use of this device.
To develop a standard training program, information was collected by studying literature, observing training in the use of CCTVs, discussing the content of the training program with professionals and organizing focus and discussion groups. The effectiveness of the program was evaluated in an RCT, to obtain an evidence-based training program. Dutch patients (n = 122) were randomized into a treatment group: normal instructions from the supplier combined with training in the use of CCTVs, or into a control group: instructions from the supplier only. The effect of the training program was evaluated in terms of: change in reading ability (reading speed and reading comprehension), patients' skills to operate the CCTV, perceived (vision-related) quality of life and tasks performed in daily living.
The development of the CCTV training protocol and the design of the RCT in the present study may serve as an example to obtain an evidence-based training program. The training program was adjusted to the needs and learning abilities of individual patients, however, for scientific reasons it might have been preferable to standardize the protocol further, in order to gain more comparable results.
Trial registration, identifier: NTR1031
PMCID: PMC2850334  PMID: 20219120
10.  Co-morbidity and visual acuity are risk factors for health-related quality of life decline: five-month follow-up EQ-5D data of visually impaired older patients 
Co-morbidity is a common phenomenon in the elderly and is considered to be a major threat to quality of life (QOL). Knowledge of co-existing conditions or patient characteristics that lead to an increased QOL decline is important for individual care, and for public health purposes. In visually impaired older adults, it remains unclear which co-existing conditions or other characteristics influence their health-related QOL. Our aim was to present a risk profile of characteristics and conditions which predict deterioration of QOL in visually impaired older patients.
Analyses were performed on data from an observational study among 296 visually impaired older patients from four Dutch hospitals. QOL was measured with the EuroQol-5D (EQ-5D) at baseline and at five-month follow-up. Nine co-existing condition categories (musculoskeletal; diabetes; heart; hypertension; chronic obstructive pulmonary disease (COPD) or asthma; hearing impairment; stroke; cancer; gastrointestinal conditions) and six patient characteristics (age; gender; visual acuity; social status; independent living; rehabilitation type) were tested in a linear regression model to determine the risk profile. The model was corrected for baseline EQ-5D scores. In addition, baseline EQ-5D scores were compared with reference scores from a younger visually impaired population and from elderly in the general population.
From the 296 patients, 50 (16.9%) were lost to follow-up. Patients who reported diabetes, COPD or asthma, consequences of stroke, musculoskeletal conditions, cancer, gastrointestinal conditions or higher logMAR Visual Acuity values, experienced a lower QOL. After five months, visual acuity, musculoskeletal conditions, COPD/asthma and stroke predicted a decline in QOL (R2 = 0.20). At baseline, the visually impaired older patients more often reported moderate or severe problems on most EQ-5D dimensions than the two reference groups.
In visually impaired older patients, visual acuity, musculoskeletal conditions, COPD/asthma and stroke predicted a relatively rapid decline in health-related QOL. With this risk profile, a specific referral by the ophthalmologist to another sub-specialty may have a beneficial effect on the patient's health-related QOL. A referral by the ophthalmologist or optometrist to a multidisciplinary rehabilitation service seems appropriate for some patients with co-morbidity. The current results need to be confirmed in studies using pre-structured questionnaires to assess co-morbidity.
PMCID: PMC2654874  PMID: 19243624

Results 1-10 (10)