Ophthalmic Epidemiology, 14:103–111ISSN: 0928-6586 print / 1744-5086 onlineCopyright c© 2007 Informa HealthcareDOI: 10.1080/09286580601052167

Vision Rehabilitation: Recipients’ Perceived Efficacyof Rehabilitation

C. Walter,1 R. Althouse,1 H. Humble,2 W. Smith,2 and J. V. Odom2

1West Virginia Survey Research Center, West Virginia University, Morgantown, West Virginia, USA2West Virginia University Eye Institute, Robert C. Byrd Health Sciences Center, Morgantown, West Virginia, USA

ABSTRACT

Objective/Purpose: This survey was conducted to determine the effect on activities of dailyliving of persons who report that they have received vision rehabilitation. Design/Methodology:This study used a clinical sample to gather information from 417 patients. Of the 417, 105 re-ported receiving vision rehabilitation. The efficacy of rehabilitation was assessed by asking20 questions about their activities of daily living prior to and after their rehabilitation. A retro-spective pretest (post-then-pre) design was used. Paired t tests were conducted to evaluate theeffect of rehabilitation. Results: A significant difference was found for 13 of 20 questions. Dif-ficulty reading ordinary prints in newspapers showed a large effect size (p = 0.0005). Difficultyreading the small print in a telephone book showed a large effect size (p = 0.0005). Difficultydoing work or hobbies that require one to see up close showed a moderate effect size (p =0.0005). Difficulty finding something on a crowded shelf showed a moderate effect size (p =0.0005). Difficulty figuring out whether bills received are accurate showed a moderate effectsize (p = 0.0005). Difficulty shaving, styling one’s hair, or putting on makeup showed a smalleffect size (p = 0.016). Difficulties seeing and enjoying programs on television showed a mod-erate effect size (p = 0.0005). Conclusion: Patients with low vision who report having receivedvision rehabilitation show significant improvements in activities of daily living or specific typesof functioning after rehabilitation. Improvement in both near and distance vision activities andin social activities indicates daily functioning was improved and that barriers to activities ofdaily living were removed.

INTRODUCTION

Low vision reduces an individual’s ability to perform every-day activities with the usual ease of the non-low-vision popu-lation. The trouble a patient has while conducting an activity isdependent on the difference between their visual ability and theamount of visual ability needed to perform the activity. Low-vision rehabilitation is designed to increase the visual ability

Received 21 February 2005; Accepted 1 October 2006.Keywords: Activities of daily living, Vision rehabilitation, Lowvision, Outcomes.Correspondence to:J. Vernon OdomWest Virginia University Eye InstituteRobert C. Byrd Health Sciences CenterMorgantown, West VirginiaUSAemail: odomj@rcbhsc.wvu.edu

(usable sight) or decrease the visual ability needed to perform anactivity.1−4 In other words, low-vision rehabilitation is designedto reduce the effect of a functional disability and facilitate an in-dependent lifestyle.5 For these reasons, rehabilitation is a valuedintervention and has an important impact on individuals’ livesand activities.6

Prior to the 1980s, patients’ visual acuity was thought torepresent visual function and provide a sufficient measure ofthe outcome treatment or of rehabilitation. Over time, prac-titioners and researchers have developed the outlook that vi-sual acuity may not represent many features of a patient’s vi-sual function.7−9 Furthermore, visual acuity, contrast sensitiv-ity, and visual fields are considered inadequate predictors ofa person’s overall disability.10 A patient with visual acuity of20/200 may function “better” than those with visual acuity of20/40. The difference between the two is best explained whenthe patients evaluate their own functioning in their everydayenvironments.2

When rehabilitative programs are evaluated, it is important tonote that success can vary, depending on the focus and strengths

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of individual programs. For example, a program may be suc-cessful at specific outcomes, but the success may be limited bythe lack of breadth or depth in the program. Low-vision reha-bilitation is multifaceted, incorporating both devices and train-ing. Programs may differ greatly in their variety and concen-tration of services.4 Research studies that focus on describingspecific outcomes of low-vision rehabilitation rather than theentirety of outcomes may not be relevant in measuring rehabil-itation services and their effectiveness.6,11,12 This has led to in-terest in using quality of life to measure outcomes of low-visionservices.4,13−20 Patient evaluation of health-related quality oflife and activities of daily living is an advantageous alternativefor the assessment of outcomes.6

Quality of life is a concept that allows for patient evaluation.It recognizes that there is a close relationship between health,socioeconomic condition, family and community support, andintegration. Quality of life assumes an individual’s health can-not be separated from these issues and must be examined in thecontext of the individual’s situation.21 There are many charac-teristics of quality of life for an individual; it is not unidimen-sional. These include physical characteristics, which consist ofthe disease symptoms and their treatment. Social characteristicsinclude social interaction and relationships with others. Psycho-logical characteristics include cognitive processes, emotionalwell-being, and overall satisfaction. Finally, the functional char-acteristics consist of the patients’ ability to care for themselves,their mobility, and physical activity, as well as activities of dailyliving.4,9,22 The combination of these features gives an indica-tion of the patients’ evaluation of their quality of life and anindication of the effectiveness the rehabilitation process has onthe individual’s activities of daily living.

Often a patient’s ability to perform activities of daily livingcomprises a portion of quality of life assessment. Activities ofdaily living can be separated into two categories: instrumen-tal (e.g., face recognition and reading) and the basic self-careactivities of daily living (e.g., eating and dressing).10 Clinicalvision measures can be “good” predictors of overall activitiesof daily living performance, especially contrast sensitivity andvisual fields. 10

The rehabilitation process is designed to help patients per-form everyday activities and reduce the impact of disabilitycaused by low vision. Recognition that patient evaluation is use-ful in the overall evaluation of rehabilitation process has led tointerest in using quality of life as an assessment tool. Often pa-tient performance of activities of daily living forms a segmentof quality of life assessments. These features give an indicationof the effectiveness that rehabilitation has had on patient activ-ities of daily living. The purpose of this study is to determinethe influence rehabilitation had on activities of daily living. Theevaluation was conducted 1) to determine the progress of theWest Virginia University’s Eye Institute in rehabilitating indi-viduals with low vision and 2) because of the expected increasein low-vision rates with the predicted increased aging of thepopulation in this country and worldwide,12,23 evaluating activ-ities of daily living is crucial to determining the effectiveness ofrehabilitation.

Program evaluations most commonly use an assessmentprior to rehabilitation and following rehabilitation. This pre-post design has been faulted for introducing biases in the postassessment.24−26 Consequently, a post-then-pre or retrospectivepretest design in which respondents are asked after an inter-vention about their status prior to the intervention has been usedsuccessfully.27,28 The retrospective pretest design may introduceits own biases, distortions of memory, etc.29 In comparisons ofthe pre-post and post-then-pre designs, they tend to yield similarbut not exactly equivalent results.30 At least under some circum-stances, the post-then-pre design provides a more conservativeestimate of change.31 In addition to the potential theoretical ad-vantages, the design has the advantage of being simpler to con-duct as one only has to determine patients’ evaluations on oneoccasion after the intervention.32 For both the potential theoret-ical advantages and the clear practical advantages of decreasedcost and time, we chose to use the retrospective pretest designin our evaluation.

DESIGN/METHODOLOGY

Instrument

A telephone survey was conducted to gather informationabout patients’ low-vision rehabilitation. To understand the ef-ficacy of rehabilitation, two surveys were used: One survey wasused to record the self-report of an adult respondent in the house-hold who received low-vision rehabilitation. The second wasused to record the responding adult’s surrogate response forfamily members who reported having low vision and receivedrehabilitation. The instrument had 20 questions about activitiesof daily living and asked patients to rate the difficulty of theactivities. The patients’ difficulty was rated on a scale of 1 to7. The response choices were no difficulty; a little difficulty;moderate difficulty; extreme difficulty; stopped doing this be-cause of your eyesight; stopped doing this for other reasons/notinterested; and don’t know. Responses 6 (stopped doing this forother reasons/not interested) and 7 (don’t know) were scored asmissing data.

The survey asked patients to recall their difficulty with theseactivities before they received rehabilitation. They were thenasked if they received rehabilitation. If they answered yes, theywere then asked how they perceive their vision after rehabilita-tion. The questionnaire was adapted from an earlier question-naire used in a previous telephone survey.33 The modificationsconsisted primarily of adding item stems asking about the pa-tients’ functioning prior to low-vision rehabilitation. These ac-tivities were expected to be responsive to near magnification,distance magnification, and functional skills training. The origi-nal telephone survey adapted many items from the National EyeInstitute Visual Functioning Questionnaire −25 (VFQ-25).34

This survey was administered from August 2003 until De-cember 2003. The sample consisted of all patients who were seenin the West Virginia University Eye Institute’s low-vision clinicbetween August 2002 and August 2003. All survey proceduresand questions complied with guidelines for survey research

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created by the West Virginia University Institutional ReviewBoard for Human Subjects and are consistent with the principlesfor human research established in the Declaration of Helsinki.

Subjects

The sample frame consisted of 879 patients who were se-lected by the use of a code assigned by WVU Eye Institute thatclassifies the patients as having received low-vision rehabilita-tion. A telephone survey was conducted to gather informationfrom the 879 patients. Four hundred seventeen of 879 patientsresponded to the telephone survey and were interviewed. Fromthe 417 who responded, 337 were categorized as having lowvision. A low-vision classification was assigned to those whostated they have moderate to extreme difficulty reading ordinaryprint in newspapers or stopped reading because their eyesightno longer permits the activity. After the respondents were clas-sified as having low vision, they were then asked if they receivedrehabilitation. If they answered yes, they were asked how theyperceive their vision after rehabilitation. The perceived efficacyof rehabilitation was measured by asking the same 20 questionsabout patients’ activities of daily living. From the 337, a totalof 105 reported receiving rehabilitation. These 105 are used forthis analysis.

Analysis

Although Likert-type items, such as those in our question-naire, are usually regarded as ordinal scale items and, therefore,are often tested for significance using nonparameteric statisti-cal tests, we chose to use parametric tests for several reasons.First, we wished to evaluate an overall measure of significanceprior to tests for individual items, and such tests are not read-ily available using nonparametric statistics. Second, reviews ofthe use of parametric statistics indicate that parametric statis-tics are robust to violations of their assumptions so that thereis not an increase in their type 1 and type II error rates whenused to evaluate ordinal data such as Likert-type items.35 Third,we conducted nonparametric statistics tests, Wilcoxon signedrank test and sign test, which did not differ from the paramet-ric tests in their significance. In addition to the mean ranks, wereport the percentage of patients who report less difficulty withspecific activities of daily living. The percentage is calculatedbased on the proportion of all patients who responded to thespecific question who reported an improvement in their abilityto perform the task. All tests were conducted using the Statisti-cal Package for the Social Sciences (SPSS). Despite the recentintense interest in the application of Rasch analysis to quality oflife scales,4,7−9 we did not use Rasch analysis. Rasch analysismakes a number of assumptions that we did not think were met.Two of the more important assumptions are that there is a sin-gle underlying dimension and that there is no guessing on thepart of the respondents. We assumed that the items that we usedconstituted a several dimension and that on some occasions thepatients’ responses were guesses.

A multivariate analysis of variance (MANOVA, Wilks’Lambda) was used to determine if there was an overall sta-

tistically significant difference between patients’ perceptions oftheir ability to perform activities of daily living. Paired-samplest tests were conducted to evaluate the effect rehabilitation hadon the patients. The paired-samples t test procedure comparesthe means of two variables that represent the same group atdifferent times. A low significance value for the t test (<0.05)indicates that there was a significant difference between the twomean scores. The procedure for calculating and interpreting themagnitude of the intervention (rehabilitation) effect was eta-squared. This set of statistics indicates the relative magnitude ofthe differences between means. The guidelines used to interpreteta-squared values are 0.01 = small effect, 0.06 = moderateeffect, and 0.14 = large effect.36

Program

The West Virginia University Eye Institute has a compre-hensive low-vision center. The center evaluates blind and vi-sually impaired individuals of all ages with a goal-orientedapproach that includes educational recommendations, commu-nity and work integration/re-integration, independent living, andimprovement of overall quality of life. Services provided bythe center include comprehensive low-vision examinations andfunctional vision assessments, activities of daily living assess-ments, orientation and mobility evaluations, counseling, com-munity referrals, and device funding. Optical and non-opticaldevices, assistive technology, computer software, and rehabili-tation strategies are evaluated and implemented to help meet thepatient’s goals and needs.

A multidisciplinary team that includes a residency-trainedlow-vision optometrist, occupational therapist, social worker,orientation and mobility instructor, and vision teacher pro-vides these services and evaluations. The rehabilitation pro-cess usually begins with an initial intake with the social workerfollowed by a functional vision evaluation performed by thelow-vision optometrist. Device recommendations are made, andpatients are educated on their remaining visual function andstrategies/devices to maximize it. The occupational therapistthen helps in integrating the optical/non-optical devices withrehabilitation strategies.

The occupational therapist usually concentrates on activitiesof daily living and integrating low-vision devices into a patient’sdaily routine. The rehabilitation process usually consists of atleast two visits, but depending on the quantity of needs/goals andthe patient’s motivation, multiple visits may be needed. Commu-nity education, clinical outreach, and mentoring are also criticalactivities provided by the team to help create awareness of theneed for low-vision services as well as to ensure services areavailable to those who cannot access the Eye Institute.

RESULTS

Demographics

From the 337 patients, a total of 105 reported receiving re-habilitation. From this group there were 70 or (67%) femalesand 35 or (33%) males with a mean age of 70.8 years old.

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Eighty-seven percent were unemployed; 7.6% were employed;and 5.7% were not counted. Eighty-nine percent had medicalinsurance; 5.7% had no medical insurance; and 5.7% were notcounted. Forty-seven percent earned less than $20,000 a year.Fifteen percent made between $20,000 and $39,999 a year. Ninepercent made above $40,000 a year. Twenty-nine percent did notknow or did not answer this question.

From the 337 patients, a total of 232 people received rehabil-itation services from the low-vision clinic but were unaware ofthat fact. From this group there were 148 or (64%) females and84 or (36%) males with a mean age of 70.9 years old. Eighty-one percent were unemployed; 6% were employed; and 13%were not counted. Seventy-nine percent had medical insurance;3.4% had no medical insurance; and 17.2% were not counted.Forty-two percent earned less than $20,000 a year. Twenty-twopercent made between $20,000 and $39,999 a year. Four percentmade above $40,000 a year. Thirty-two percent did not know ordid not answer this question.

A MANOVA (Wilks’ Lambda) indicated a statistically sig-nificant difference (p = 0.009) between patients’ perceptions oftheir ability to perform activities of daily living. There was nosignificant interaction effect (p > 0.05). To determine if therewere specific activities that showed a greater difference, we useda series of planned comparisons using t tests for related sam-ples to determine statistical significance. In addition to the meanranks, we report the percentage of patients who report less dif-ficulty with specific activities of daily living. The percentage iscalculated on the basis of the proportion of all patients who re-sponded to the specific question who reported an improvementin their ability to perform the task. All tests were conductedusing the Statistical Package for the Social Sciences (SPSS).

Question classification

Near-vision activities

We grouped the questions in this study into three groups.The first group dealt with near-vision activities that benefit frommagnification and activities that benefit from functional skillstraining. Figure 1 presents the percentage of patients who re-ported improvement in near-vision activities as a function ofall patients who responded to both the pretest and posttestquestions. Table 1 presents the question stems used in theanalyses, the patients’ mean ratings for before and after low-vision rehabilitation, and the statistical significance of the dif-ference in ratings for paired t tests. There were 11 questionsclassified as near-vision activities. The questions all showedimprovement; however, only 9 of the 11 were statistically sig-nificant. From the nine, six showed large improvement afterrehabilitation, two questions showed moderate improvement,and one showed little improvement. The questions asked howmuch difficulty they have performing the activities indicated inTable 1.

Distance-vision activities

The second classification dealt with distance-vision activ-ities that benefit from telescopic-magnification and/or func-tional skills training. There were three questions classified asdistance-vision activities; however, one of these questions alsofalls into the third classification. Figure 2 presents the percent-age of patients who reported improvement in distance-visionactivities as a function of all patients who responded to boththe pretest and posttest questions. Table 2 presents the question

Figure 1. Change in near-vision activities after rehabilitation. The percentage of patients who reported improvement in an activity as a functionof all patients who responded to both the pretest and posttest questions is presented. The question label is indicated on the vertical axis and thepercentage on the horizontal axis. The activities associated with the questions are indicated in Table 1.

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Table 1. Near activities

Before AfterQ1. Reading ordinary print in newspapers 4.4231 3.5∗∗∗Q2. Reading small print in a telephone book 4.6117 3.7379∗∗∗Q3. Doing work or hobbies that require you

to see well up close4.2970 3.7921∗∗∗

Q4. Playing cards or games such as bingo ormonopoly

4.2078 3.8182∗∗∗

Q5. Finding something on a crowded shelf 3.6154 3.1758∗∗∗Q7. Going down steps, stairs, or curbs in the

daytime3.0612 2.8776∗∗∗

Q8. Going down steps, stairs, or curbs in dimlight or at night

3.6042 3.3750∗∗

Q12. Figuring out whether bills you receiveare accurate

4.1979 3.5417∗∗∗

Q14. Shaving, styling your hair, or putting onmakeup

3.1010 2.8687∗∗

Q9. Noticing objects off to the side while youare walking

3.1183 2.9677

Q13. Picking out and matching your ownclothes

2.8020 2.6535

∗ =< .05 ∗∗ =< .01 ∗∗∗ =< .001Similar results were obtained using Wilcoxon’s test and the sign test. Allratings referred to level of difficulty with an activity. Therefore, lowerrating represent less difficulty and a reduction in mean ratingrepresents improvement.

stems used in the analyses, the patients’ mean ratings for be-fore and after low-vision rehabilitation, and the statistical sig-nificance of the difference in ratings for paired t tests. Thequestions all showed improvement, and all were statisticallysignificant. From the three, one showed large improvement af-ter rehabilitation, one question showed moderate improvement,and one showed little improvement. The questions asked howmuch difficulty they have performing the activities indicated inTable 2.

Vision-related social activities

The third classification dealt with social activities that ben-efit from group activities and functional skills training. Thereare seven questions classified as social activities; one of whichalso falls in the distance vision classification. Figure 3 presentsthe percentage of patients who reported improvement in socialvision activities as a function of all patients who responded toboth the pretest and posttest questions. Table 3 presents the ques-tion stems used in the analyses, the patients’ mean ratings forbefore and after low-vision rehabilitation, and the statistical sig-nificance of the difference in ratings for paired t tests. Questionsin social activities all showed improvement; however, they werenot all statistically significant. From the seven, two questionsshowed a statistical significance. One question showed moder-ate improvement after rehabilitation and one showed little im-provement. Five questions showed no statistical significance,but four of the five showed mean scores that improved. The onequestion that did not show improvement asked, “How much dif-ficulty do you have taking part in active sports or other outdooractivities that you enjoy?” The lack of improvement could be re-lated to the mean age (70.8) of our sample. The questions askedhow much difficulty the patients have performing the activities(Table 3).

DISCUSSION

Twenty questions were used to conduct a before and afteranalysis of the rehabilitative process on activities of daily liv-ing. The assumption that visual function is best explained by theindividual’s assessment of their performance in their everydayenvironment guides this research.2 Despite this, a combinationof measuring an individual’s assessment and their visual impair-ment would have strengthened this analysis given that clinicalvision measures are good predictors of overall activities of daily

Figure 2. Change in distance-vision activities after rehabilitation. The percentage of patients who reported improvement in an activity as afunction of all patients who responded to both the pretest and posttest questions is presented. The question label is indicated on the vertical axisand the percentage on the horizontal axis. The activities associated with the questions are indicated in Table 2.

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Table 2. Distance activities

Before AfterQ6. Reading street signs or the names of

stores3.7677 3.5657∗∗∗

Q10. Recognizing people you know fromacross a room

3.7374 3.5051∗∗

Q18. Seeing and enjoying programs ontelevision

3.5051 2.9192∗∗∗

∗ =< .05 ∗∗ =< .01 ∗∗∗ =< .001The question stems are indicated as are the patients mean ratings forbefore and after low-vision rehabilitation. The statistical significance ofthe difference in ratings is indicated by the number of asterisks placednext to the after mean rating. The statistical significance levels reportedare for paired t tests. Similar results were obtained using Wilcoxon’s testand the sign test. All ratings referred to level of difficulty with an activity.Therefore, lower rating represent less difficulty and a reduction in meanrating represents improvement.

living performance.10 Nevertheless, there was an overall statis-tically significant difference in the questions about the patients’perception of their ability to perform activities of daily living.When determining the specific activities that showed a greaterdifference, 13 questions from the survey responded to the effectsof rehabilitation. Patients perceived a significant increase in theirvisual functioning after undergoing rehabilitation, as did sevenquestions from an earlier study.4 One question is placed in mul-tiple categories. This question will be included in the discussionfor each of the classifications it falls under.

Rehabilitation knowledge

Twenty questions related to activities of daily living wereadapted from the WV Visual Health Survey and used to evaluate

the effects of low rehabilitation on activities of daily living usinga retrospective pretest design. There was an overall statisticallysignificant difference in the questions about the patients’ percep-tion of their ability to perform activities of daily living. Patientsperceived a significant increase in their visual functioning afterundergoing rehabilitation. Thirteen of the 20 questions from thesurvey responded to the effects of rehabilitation. This is con-sistent with previous results, which also found improvements inseven questions related to activities of daily living.4 For purposesof discussion, we have grouped the questions into three groups,near-vision-related activities, distance-vision-related activities,and vision-related social activities. One question is placed inmultiple categories and will be included in the discussion foreach of the classification it falls under.

Near-vision activities

Eleven of the 20 questions were about near-vision activities,which can be improved by magnification, and activities that canbe improved by functional skills training. From the 11, 9 werestatistically significant, and 6 of these indicated a large improve-ment after rehabilitation. The two items in this group that didnot show improvement were detecting objects to the side andpicking out one’s clothes.

People who received rehabilitative services were likely to im-prove in areas that require near magnification. Improvement inactivities necessary to read bills, read smaller print, and seeclose up supports the idea that survival or spot reading ac-tivities, which are necessary in the performance of activitiesof daily living, are improved and should be a focus of re-habilitative services.12,37−48 Furthermore, these findings sup-port the idea that low-vision aids were a successful meansof providing visual rehabilitation and helped patients with

Figure 3. Change in vision-related social activities after rehabilitation. The percentage of patients who reported improvement in an activity asa function of all patients who responded to both the pretest and posttest questions is presented. The question label is indicated on the verticalaxis and the percentage on the horizontal axis. The activities associated with the questions are indicated in Table 3.

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Table 3. Vision-related social activities

Before AfterQ10. Recognizing people you know from

across a room3.7374 3.5051∗∗

Q11. Seeing peoples’ physical reactions towhat you are saying

3.4767 3.2791∗

Q15. Conducting normal social activities 3.1596 3.0957Q16. Entertaining friends and family in your

home2.5319 2.3936

Q17. Visiting with people you do not know wellin their homes

3.4359 3.3846

Q19. Taking part in active sports or otheroutdoor activities that you enjoy

3.3929 3.4643

Q20. Going out to see movies, plays, or sportsevents

4.00 3.9104

∗ =< .05 ∗∗ =< .01 ∗∗∗ =< .001The question stems are indicated as are the patients mean ratings forbefore and after low-vision rehabilitation. The statistical significance ofthe difference in ratings is indicated by the number of asterisks placednext to the after mean rating. The statistical significance levels reportedare for paired t tests. Similar results were obtained using Wilcoxon’stest and the sign test. All ratings referred to level of difficulty with anactivity. Therefore, lower rating represent less difficulty and a reductionin mean rating represents improvement.

low vision to read.41 Other research indicates issues such aspreferred retinal locus, ability in fixation, and saccadic eyemovements and cognitive ability are extensively implicatedin shaping reading rates in people with vision problems.40

Nevertheless, the survey used did not allow for the distinc-tion between reading ability and reading speed, duration orcomprehension.

Two items that were not directly related to improvements innear magnification also showed improvement. These items wererelated to going up and down stairs.

Distance-vision activities

Three of the 20 questions involved distance-vision activi-ties. Presumably these activities would be improved by distancemagnification (e.g., telescopes). All three were statistically sig-nificant and one of these indicated a large improvement, onea moderate improvement, and one a small improvement afterrehabilitation. Distance-vision activities that help individualsnavigate their environment are improved by vision rehabilita-tion. Prior research has indicated that telescopic lenses helpedin navigation of patients’ environments, seeing objects from adistance, shopping, seeing movies, reading signs, and recog-nizing faces of people.42 Subjects who were simply prescribedtelescopic lenses and had no training showed improvement invisual skills such as mobility, tracking, and visual memory.The difference between the untrained and trained groups be-came significant when driving-related skills were assessed.42

Bioptic driving is not permitted in West Virginia; therefore,this study did not evaluate driving skills before and afterrehabilitation.

Social activities

Social activities contribute to an individual’s ability to func-tion both before and after rehabilitation.43 Seven questions in-volved social activities, two of which showed a statisticallysignificant improvement. These questions regard social activ-ities and communication among family, friends, and strangers.This is important in providing information, directions, andexpressions.44 Five of these questions were not statistically sig-nificant. “However, four of the five questions’ mean scoresshowed improvement. Improvement in social activities couldindicate an indirect effect from the improvements in the othertwo vision categories. The one question that did not show im-provement, “How much difficulty do you have taking part inactive sports or other outdoor activities that you enjoy?”, maybe more related to the age of the population and other healthproblems than to a specific failure in low-vision rehabilitation.Age-related physical limitations are among the deficits that arepotentially most intrusive to elderly persons.45 The general im-provement for this category is encouraging, whether low-visionrehabilitation indirectly or directly improved the activities.

Unlike mental health rehabilitation, vision rehabilitation doesnot primarily focus on improving social activities. Past researchnoted low-vision patients raised questions and concerns aboutdepression, safety, loneliness, and anxiety about coping.12,45

These psychosocial barriers can have an impact on and im-pede access to health care.46 Serious vision loss can restricta person’s ability to carry out activities of daily living, whichimpedes functioning.45 Low vision can have a significant im-pact on an individual’s life and causes important psychosocialand functional changes.46 Nevertheless, there is agreement thatpatients can satisfy their needs, interests, and desires throughgroup experiences. Because low vision has such a strong im-pact on one’s life, it may require a rehabilitative focus on groupinteraction. Learning correct responses to situations, achiev-ing rewards for participation, making new friends, and attain-ing respect and prestige serve as positive reinforcement. Ulti-mately, this process leads to social adjustment, which is neededfor success in a vocation, in family living, and in communityactivities.47

Rehabilitative focus

For rehabilitation to be defined as successful, three factorsmust be accomplished. The first factor is the primary objectiveof care is focused on the individual’s daily functioning. This isthe typical standard used to gauge success of rehabilitation ser-vices and is also used for reimbursement. The second factor is theassertion that functioning is a product of biological, psycholog-ical, and social influences working in conjunction. Functioningcan be limited when this balance is affected by low vision. Thethird factor states rehabilitation is achieved in two ways: removalof barriers, which slows or prevents improved functioning, andthe provision of therapies to improve daily function. If rehabil-itation is to be successful, these factors must be addressed, andthe improvement in functioning or the removal of obstacles mustoccur.42

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In conclusion, this study shows significant improvements inactivities of daily living after rehabilitation. Improvement in ac-tivities associated with near and distance vision as well as socialactivities indicate that low-vision rehabilitation improved dailyfunctioning. In general, many barriers to normal functioningwere removed by improved ability to perform activities of dailyliving. Although many activities were improved, vision-relatedsocial activities were much less likely to improve. This mayindicate a need to more specifically target this area of activi-ties. Vision rehabilitation proved relatively effective at improv-ing the functions it targeted. Although we had a social worker,her function at the time of the study was primarily one of finan-cial counseling and assisting patients without financial resourcesin finding alternative payers for the assistive technology theyneeded. She was not in a position to target social functioning ina systematic manner.

If rehabilitation were to focus on social activities, it wouldprovide methods to improve social function and remove barriersto social function. Counseling for psychosocial issues relatedto vision loss can also assist in the adjustment to loss of inde-pendence, control, burdened and stressed social relations, andlow self-esteem.47 One suggestion is that vision rehabilitationprograms might target these social functions more explicitly.However, this also implies that rehabilitation efforts targeted to-ward improvement in social activities are reimbursed and thatthe persons providing these services have appropriate training.

ACKNOWLEDGMENT

This research was supported in part by CMS 18-C-9137212from the Center for Medicare and Medicaid Services and R03EY 14841 from the National Eye Institute to JV0.

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