Award Title: Improving diagnosis and rehabilitation of visual perception problems after stroke
Funder: Department of Health and Social Care

Abstract: BACKGROUND Of the 100,000 people a year in the UK who suffer a stroke, up to 76% are left with visual perception problems. These problems are distinct from sensory vision like reduced visual fields or reduced visual acuity and, instead are related to difficulties in interpreting the images from the eye such as needed for object recognition, reading, or eye-hand coordination. Due to a lack of systematic screening with time-consuming standardised tests, an estimated 75% of patients with these visual perception problems are not diagnosed and guidelines on rehabilitation are limited. Patients therefore do not receive the rehabilitation they need. I have developed a practical screening tool for visual perception problems that can be used to systematically screen all stroke survivors. AIM I aim to transform my prototype screening tool into a functional, comprehensive tool and identify the most appropriate rehabilitation methods. In this way, I hope to create a practical, operational package for everyday use in the NHS. OBJECTIVES, METHODS, DELIVERABLES AND TIMELINE Objective 1 is to update images of three tasks of my prototype (months 1-9). I will establish the normal range of scores on tasks with the new images in an online observational study with 80 healthy volunteers. This work package will deliver 12 updated pictures for the screening tool. Objective 2 is to evaluate reliability and diagnostic accuracy of my screening tool (months 6-39). To achieve this, 109 stroke survivors will complete the new screening tool (twice), a gold standard visual perception test and tests for cognition (e.g. language, memory) and sensory vision. This work package will deliver measures of test-retest reliability, sensitivity and specificity, convergent and discriminant validity. Objective 3 is to develop rehabilitation recommendations as a follow-up pathway for my screening tool. I will update an ongoing evidence synthesis of interventions (months 12-18) and involve six nominated international experts to develop recommendations (months 18-30). Next, I will discuss feasibility/acceptability with stakeholders (clinicians, patients, behaviour change scientists) (months 21-30). This work package will deliver rehabilitation recommendations for each visual perceptual problem that my screening tool screens for. ANTICIPATED IMPACTMy research will increase awareness amongst researchers and clinicians about the assessment and rehabilitation options for visual perceptual problems after stroke. Furthermore, my tool can become the new gold standard for assessment of visual perception problems after stroke. With my screening tool, non-specialist clinicians would be able to screen stroke survivors for visual perception problems in 15 minutes. The rehabilitation recommendations would make it truly unique and desirable for clinicians. It would give them a tool set to deliver best-practice rehabilitation. These measures can have life-changing impact for patients. They would increase a patient's independence and self-esteem. Even without treatment, a clear diagnosis can offer reassurance and reduce anxiety. DISSEMINATION TO STAKEHOLDERS Clinicians: professional development opportunities, updated leaflets with professional bodies, presentation at regional and national meetings, UK Stroke Forum and social media engagement. Patients: lay summaries on my website and engagement with patients' groups (e.g. Stroke Association, Clinical Research Network Stroke Patient and Carer Panel).

Lay Abstract: BACKGROUND Stroke is a common and life-threatening condition. Almost 8 in 10 stroke survivors have visual perception problems such as difficulties with recognising objects or faces. These problems hinder stroke survivors in doing everyday tasks like driving, sending a text message or meeting friends. The available screening tools for visual perception problems are time-consuming. Therefore, clinicians most often have to rely on what patients report and on their own observations. Unfortunately, many problems are missed that way. Diagnosis and rehabilitation of visual perception problems are in the top 5 research priorities set by patients and clinicians. Rehabilitation can include training (e.g. online reading training), adaptations to the environment (e.g. remove distractions), or coping strategies (e.g. use memory or other senses). Different vision problems need different rehabilitation approaches and it is important to ensure that the most appropriate rehabilitation is offered to patients for their condition. The newest rehabilitation approaches are not yet known to all clinicians and are therefore not offered to all patients. A screening tool for visual perception problems is the first critical step to resolve the problem. Next, up-to-date recommendations for rehabilitation are essential. I have already developed a novel screening tool for visual perception problems. It has tasks such as naming pictures, recognising faces, and reading text. To my knowledge, my screening tool is the only one that is quick to administer, making it suitable for use in busy clinical settings and that is based on recent scientific insights on how the brain works. AIM I will now test if my screening tool gives similar results to the current best practice test (that is accurate but time-consuming). I will also develop recommendations for rehabilitation. In the long term, this will allow clinicians to quickly screen for visual perception problems after stroke and provide each patient with the best possible rehabilitation. These measures should have life-changing impact and enable stroke survivors to live independently for longer. DESIGN AND METHODS Screening tool I will investigate how well my screening tool can identify stroke survivors with visual perceptual difficulties compared to the current best practice visual perception test. I will also research if we get similar test results when administering the test to the same patients on two occasions. Rehabilitation recommendations I will review the literature on rehabilitation and consult clinical experts (e.g. occupational therapists, psychologists) and stroke survivors through structured brainstorming sessions. I will use this information to inform development of recommendations for rehabilitation that are effective and acceptable. PATIENT, CARER, AND PUBLIC INVOLVEMENT Ten stroke survivors, carers and members of the public have been involved in designing this research proposal. They gave feedback on which research questions to prioritise, how to make sure that the research procedures were acceptable to participants and how patients could be involved in the future. During the fellowship, I will meet with the Stroke Patient and Carer Panel North East and North Cumbria to ask their advice on patient information sheets, recruitment, the acceptability of research procedures, and sharing research findings. I also plan to involve two stroke survivors as a members of my steering committee, which will oversee the project, and as members of the panel that decides on which rehabilitation to recommend. DISSEMINATION I will share my results with clinicians at professional development opportunities organised by professional bodies for occupational therapists, psychologists, and the UK Stroke Forum. I will share my results with stroke survivors and their carers through my contacts with the Stroke Association, radio stations for visually impaired, Stroke Patient and Carer Panels, Stroke4Carers.org, lay summaries on my website, and through social media.

Research Activity Codes: 7.1 INDIVIDUAL CARE NEEDS
Health Categories: STROKE;EYE