PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS

, VOL. , NOS. -, –

https://doi.org/./..

Evaluation of Cognitive Functioning in the Context of

Rehabilitation for Visual Impairment in Older Adults:
A Case Series
Marie-Ève Gervaisa , Mélanie Couturea , Stéphanie Le Blanca , Sophie Blancheta,b ,
Marie-Ève Gagnéa,c , and Marie-Christine Ouelleta,c
a
Institut de réadaptation en déficience physique de Québec, Center for Interdisciplinary Research in
Rehabilitation and Social Integration (CIRRIS), Québec, Canada; b Université René Descartes - Paris , Paris,
France; c School of Psychology, Université Laval, Québec, Canada

ABSTRACT ARTICLE HISTORY

Aims: As the risk of visual impairment increases with age, so does Received  February 
the risk of developing cognitive impairment. Detection of cogni- Revised  May 
tive deficits in people with visual impairments is a challenge and Accepted  June 
it remains unclear to what extent cognitive issues impact daily KEYWORDS
habits and the rehabilitation process. The present study aimed Older adults; low vision
to (1) verify the consistency between the Montreal Cognitive rehabilitation; cognition; life
Assessment (MoCA) and the Mini-Mental State Examination habits
(MMSE) (“Blind” versions) and the therapist’s observations of
elderly individuals in low-vision rehabilitation (LVR), and (2)
document how cognitive difficulties may influence LVR and
the satisfactory carrying-out of life habits. Methods: Six elderly
individuals who received LVR completed the MMSE and MoCA
(“Blind” versions) and Assessment of Life Habits (LIFE-H). The
therapist rated the achievement of rehabilitation objectives,
clients’ cognitive functioning and its impact on the rehabilitation
process. Results: All participants obtained scores within the
normative score range for both tests except for one participant
on the MoCA. The therapist perceived that four out of six par-
ticipants had cognitive difficulties significant enough to hinder
the rehabilitation process and these persons required more
adaptations to therapy. All participants were satisfied with their
life habits despite remaining functional limitations and the need
for assistance. Conclusions: In this sample, standardized cognitive
tests had limited utility to predict the complexity of LVR. Even if
present, cognitive difficulties do not preclude rehabilitation for
even severe visual impairment in elderly persons and does not
imply significantly longer or more intense rehabilitation.

Introduction
In Canada, about 7% of people over 65 years of age have significant visual impair-
ment which is associated with an increased risk of institutionalization, falls, and

CONTACT Marie-Christine Ouellet, PhD [email protected] Center for Interdisciplinary

Research in Rehabilitation and Social Integration (CIRRIS), Institut de réadaptation en déficience physique de Québec
(IRDPQ),  boulevard Wilfrid-Hamel, Bureau H-, Québec (Québec), GM S, Canada.
©  Taylor & Francis Group, LLC
 PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS 133

poorer health in general (Jin & Wong, 2008). According to Statistics Canada, this
represented more than 284,000 people in 2012. In a recent study, Desrosiers and
colleagues (2009) compared the level of social participation of older adults with var-
ious types of visual impairment to persons without visual impairment by exploring
functioning in different activities and social roles. They observed significantly less
participation regarding nutrition, mobility, responsibilities (e.g., planning a budget),
community life, and recreation among older adults with visual impairment. More-
over, the association of visual impairment with other difficulties in activities of daily
living such as problems with using the telephone, shopping, or the use of medical
services is well known (Nakamura et al., 1999). In Western countries, age-related
macular degeneration (AMD) is the leading cause of legal blindness in elderly per-
sons (Kahn et al., 1977; Klaver et al., 1998) and these individuals are more dependent
on others for basic (ADL) and instrumental (IADL) activities of daily living than
older people with normal vision (Gopinath et al., 2014; Williams et al., 1998). In
addition, quality of life for individuals with bilateral AMD is significantly reduced
compared to individuals with normal vision (Hassel et al., 2006; Marback et al.,
2007).
As the risk of visual impairment increases with age, so does the risk of develop-
ing cognitive impairment. Whitson and colleagues (2007; 2010; 2014) estimate that
about 3.5–4% of community-dwelling older adults have both types of impairment. It
is plausible to presume that if present in a person with visual impairment, cognitive
deficits may represent an impediment to the successful rehabilitation of visual dis-
turbances. Indeed, cognitive impairment, even when mild, could impact learning or
relearning of skills and thus may have a significant impact on lifestyle, affecting the
more complex daily tasks such as grocery shopping, financial management or cook-
ing (Blanchet et al., 2002; Njegovan et al., 2001). To what extent cognitive issues
impact the rehabilitation process, however, remains unclear.
Several studies have reported an association between cognitive deficits and visual
loss in elderly persons (Clemons et al., 2006; Lin et al., 2004; Reyes-Ortiz et al., 2005;
Rogers & Langa, 2010). Cognitive deficits are more common and progress faster in
adults with low vision than in people with intact vision (Lin et al., 2004; Rogers &
Langa, 2010; Tay et al., 2006). Specifically, AMD has been associated with a higher
risk of dementia and decreased cognitive function (Baker et al., 2009; Klaver et al.,
1998; Pham et al., 2006; Rovner et al., 2009) and these pathologies share common
pathogenesis. To our knowledge, only Whitson’s team has examined the combined
effects of visual and cognitive impairment on functional limitations in a very large
sample of older adults. One study (Whitson et al., 2007) concluded that the coex-
istence of the two conditions increases by three to six times the risk of difficulties
in terms of mobility and impairments in ADLs. Another study by the same group
(Whitson et al., 2012), found that patients with significant memory deficits had
worse functional trajectories during low-vision rehabilitation (LVR), leading to
worse outcomes in vision-related function. These authors suggest that a short mem-
ory test could help identify patients at risk for worse outcomes in rehabilitation.
Moreover, Heyl and Wahl (2012) highlight the importance of carefully evaluating
134 M.-È. GERVAIS ET AL.

cognitive resources in people with visual impairment, as these individuals must rely
on cognitive abilities to perform ADLs and IADLs due to restricted sensory input.
Hagerman and colleagues (2007) argue that all clients can benefit from visual
impairment assessment and recommendations for rehabilitation regardless of their
cognitive status (Hagerman et al., 2007). Although the successful rehabilitation of
visual impairment in elderly persons depends on a multitude of factors, the client’s
level of cognitive functioning may influence the course and success of rehabilitation.
For example, difficulties with memory or attention could slow or complicate inter-
ventions during LVR (e.g., learning to use a technical device). In this sense, it could
be expected that an assessment of cognitive functions (including, for example, mem-
ory, attention, language, visuospatial abilities, and executive functions) should help
therapists improve intervention planning; for example, by planning for additional
services or time, involving relatives, proposing compensatory strategies, or modi-
fying therapeutic approaches (e.g., simplifying objectives, adding cues). Access to
thorough cognitive evaluations by a neuropsychologist, however, is not universal as
it entails increased costs and resources. Short cognitive screening tools exist yet it
remains unclear whether they can contribute to guide rehabilitation professionals
in this field.
Detection of cognitive deficits in people with visual impairments is a challenge.
In older adults without visual impairments, the Mini-Mental State Examination
(MMSE) and the Montreal Cognitive Assessment (MoCA) are among the most fre-
quently used tests to screen for cognitive deficits. The original MoCA is known to
be more sensitive to the presence of mild cognitive impairment (Nasreddine et al.,
2005) as the cognitive tasks required are considered to be slightly more difficult than
in the MMSE. However, the use of these tests in people with visual impairment is
a problem as they both contain visual tasks. Consequently, any slight to moderate
decrease in visual acuity (Snellen test of 20/40 or 20/60 on the map) can significantly
affect test performance, with the individual’s ability to complete the visual task being
related to the severity and the type of visual impairment. It is therefore very difficult
to determine whether errors on these items are due to visual or cognitive problems
or a combination of both (Lawrence et al., 2009). When the traditional versions of
cognitive tests are used, cognitive deficits tend to be overestimated in older adults
with visual impairment, likely because visual impairment is a confounding factor in
cognitive assessments (Bertone et al., 2005; 2007).
Some researchers have consequently adapted cognitive tests to take into account
visual impairment, by removing all visual items: for example, the “Blind” versions
of the MMSE and MoCA (Reischies and Geiselmann, 1997; Wittich et al., 2010).
These modified versions of standardized tests are known to remain sensitive enough
to detect cognitive difficulties (Busse et al., 2002; Wittich et al., 2010). For example,
Wittich and colleagues (2016) studied the usability of assistive listening devices in
elderly adults suffering from vision loss. They found that cognition, as measured by
the MoCA-Blind Version, was at least in part predictive of the success of the partici-
pants in using such devices, when other important variables such as task complexity
and the severity of the visual impairment were also taken into account. However, it
 PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS 135

remains unclear whether the results of standardized cognitive tests can be linked
to general functioning in terms of ADLs or IADLs. Finally, it is still also unclear
whether the information derived from cognitive screening tests is a useful addition
to the therapist’s clinical judgment during LVR, for example, to inform the therapist
about potential complications during occupational therapy (e.g., increased length of
therapy, adaptations to therapy).
Using a single-case research design, this study aimed (1) to verify the consistency
between the results on two standardized tests, the MoCA and the MMSE (“Blind”
versions) and the therapist’s observations about the cognitive functioning level of
elderly individuals requiring rehabilitation for visual impairment and (2) to docu-
ment how cognitive abilities, as observed by therapists and screened by standardized
tests, may influence the rehabilitation process in elderly persons with visual impair-
ments (e.g., achievement of rehabilitation objectives, adaptations needed to therapy)
and the person’s ability to satisfactorily participate in different activities.

Methods

Participants
Six elderly individuals who received occupational therapy in the Low-Vision Reha-
bilitation Program for Adults and Older Adults of the Institut de réadaptation en
déficience physique de Québec participated in this case series study. Inclusion cri-
teria were: (1) to be aged over 65, (2) to have a best corrected visual acuity of less
than 6/120 or have a field of vision in each eye of less than 60° in meridians 180°
or 90°, and (3) to be unable to read, write or move in an unfamiliar environment
(after correction by means of appropriate ophthalmic lenses, excluding special opti-
cal systems and additions above + 4.00 diopters). Persons who had a confirmed
diagnosis of dementia at the time of admission to the rehabilitation program were
not included in the study. The study was approved by the Research Ethics Board of
the Institut de réadaptation en déficience physique de Québec. Sociodemographic and
clinical characteristics of all participants are presented at the beginning of Table 1.

Procedure

Persons meeting inclusion criteria (identified via chart review) were contacted by
telephone by the team social worker to validate their interest in participating in
the project. Participants who consented to participate received rehabilitation treat-
ment as usual by an occupational therapist who was the same for all participants
in this study. Briefly, treatment as usual in this LVR program entails interventions
to develop and maintain independent living, support for social integration, adap-
tation in living environments (assessment, recommendations and training for spe-
cialized aids), interventions to facilitate mobility, use of adapted computer aids and
other devices for healthcare (assessment, training, follow-up at home, at work or
at school). In addition to these habitual interventions, the occupational therapist
 136

Table . Sociodemographic and clinical characteristics of participants, cognitive test results and observations made by the therapist throughout low-vision rehabilitation
interventions.
Participant  Participant  Participant  Participant  Participant  Participant 

Age (years)      
Marital status widowed widowed single widowed widowed widowed
Living arrangements Living alone on second Living alone in a Living alone in her Living alone in Living alone in Living alone in a studio
floor of a duplex second-floor apartment own house assisted-living residence assisted-living residence with assisted-living
M.-È. GERVAIS ET AL.

services
Education (years)      
Sex F F F M F F
Main source of social Family members Family members Family members Family members Family members Family members
support ( of her  children ( of  children live in ( nieces) + ( daughters) and ( of  children lives ( sons who visit
live nearby) same building) community services employees of a residence nearby) and employees of regularly) and
with services a residence with services employees of a residence
with services
Diagnosis AMD AMD AMD Diabetic Retinopathy and AMD AMD and disciform scar
glaucoma
Visual acuity OD: /- OD: /+ OD: light perception OD: / + OD: / OD: /
OS: /+ OS: / OS: / OS: light perception OS: / OS: /
Rehabilitation objectives . apply lipstick . use stove . decode written . apply eye-drops . use microwave . identify food items at the
. connect electrical . measure ingredients information . utility reading (magazine . write short notes grocery store and read
plugs . localize and measure . read balance on articles or bank . utility reading (schedule) prices
. write notes spices bank statement statement) . knowing the time . program phone
. proof-read notes . pour cold liquids . write short notes . differentiate coins . use the phone . utility reading (mail,
. pay bills via internet . read recipes . see the date . recreational reading . read phone numbers activity program,
. watch TV . read menus . sign papers . watch TV . identify coins and magazines, newspaper)
. recreational . look at photos . recreational reading . adequate lighting banknotes . compose bank PIN in
reading . watch TV . recreational reading stores
. play scrabble on the . knit . watch TV . thread a needle and
computer accomplish simple
. use internet sewing repairs
. recreational reading
. watch TV
. play word games
MMSE Blind (cut-off score:      
–) Subtests with Attention/calculation: Orientation: / Recall: / Attention/calculation: / Attention/calculation:
errors / Recall: / Recall: / /
Recall: / Recall: /
MoCA Blind (cut-off score:      
) Subtests where errors Attention: / ( + )a Delayed Recall: / ( + )a ( + )a (+ )a
were observed Delayed Recall: / Delayed Recall: / Orientation: / Attention: / Attention: / Attention: /
Abstraction: / Language: / Language: /
Delayed Recall: / Naming: / Naming: /
Abstraction: / Abstraction: /
Delayed Recall: / Delayed Recall: /
Therapist’s evaluation of  (cognitive difficulties  (no significant cognitive  (no significant  (cognitive difficulties  (cognitive difficulties  (cognitive difficulties
cognitive difficulties significant enough difficulties) cognitive significant enough to significant enough to significant enough to
to interfere with difficulties) interfere with interfere with interfere with
rehabilitation) rehabilitation) rehabilitation) rehabilitation)
Number of therapy sessions  (. h)  (. h)  (. h)  (. h)  (. h)  (. h)
(hours of direct
intervention)
Achievement of / achieved / achieved / achieved / achieved / achieved / achieved
rehabilitation objectives / partially / partially achieved / partially achieved / not achieved
achieved / not achieved
/ not achieved
(Continued on next page)
PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS
137
Table . (Continued)
138

Participant  Participant  Participant  Participant  Participant  Participant 

Observations during • MoCA: needs a • MoCA:  repetitions • MoCA:  repetitions • MoCA:  repetitions • MoCA:  repetitions • MoCA:  repetitions
cognitive screening test semantic cue to needed to retain the needed to retain needed to retain the needed to retain the needed to retain the
administration recall one word and -word list. the -word list. -word list. -word list. -word list.
a multiple choice • Multiple choice cues • Semantic cues • Difficulty understanding • Omits a word in the • Participant talks during
cue to recall needed for / words at needed for  words. the example for the language subtest. language subtest.
another. recall. • Fatigue reported by Abstraction subtest. • Needs a semantic cue to • Multiple choice needed to
the end of cognitive • A multiple choice cue recall one word and a recall one word.
M.-È. GERVAIS ET AL.

testing. needed to recall one multiple choice cue to

word. recall two others.
• Difficulty with calculation.
Observations during • Several repetitions • Sometimes has difficulty • Difficulty concentrating • Cannot recall how to use • Word-finding difficulties,
rehabilitation needed to teach the maintaining a during interventions. simple or complex imprecise language.
interventions use of new visual conversation topic • Difficulty learning to use functions of an electronic • Self-reports difficulty
aids (electronic • Participant self-reports an electronic reading aid. reading aid despite many remembering certain
reading aid, digital poor memory, • Difficulty with repetitions. information (e.g.,
audio-player). word-finding difficulties problem-solving and • Abandoned several telephone numbers).
• Few spontaneous and forgetting organization during the objectives because they • Able to learn to use a
behaviors to conversation topics. use of a reading aid: does are too complex sewing aid with
explore use of not apply the taught (programming phone, repetition, in a familiar
devices. strategies and does not take notes). context and with an
• Difficulty use the reminders. adapted rhythm.
understanding how • Wants to abandon the use • Repetitions needed to
to use keyboard of the electronic reading learn to use a
shortcuts. aid and closed-circuit closed-circuit television
• Difficulty performing television system. system. Able to do
a task previously • Forgets an appointment. crosswords with this aid
performed although with some
(accessing the difficulty.
internet). • Abandoned certain
• Difficulty solving activities where she feels
problems, anxious (entering her
implementing PIN in a real situation).
taught strategies.
• Abandons reading
magazines because
it is too complex.
 Therapist-initiated • Disabled certain • Use of reminders. • Use of reminders. • Simplified use of the • Use of reminders.
adaptations to therapy functions of the micro-wave. • Simplification of activity:
electronic reading • Simplification of strategies. use cash instead of card
aid. requiring a PIN.
• Use of reminders.
• Objectives simplified
by the therapist.

Participant-initiated • Takes many notes. • Counts her pills to • Simplifies or limits certain • Limits certain activities:
adaptations to • Places and finds notes ensure she does not activities: use of stove, use of stove,
impairments or efficiently. forget to take any; limits phone calls to programming phone,
compensatory strategies • Simplifies her objectives • Places an elastic on well-known numbers using bank PIN.
and needs. certain pill because has difficulty
containers. searching for a number.
• Eats her meals in a
plastic container to
guide herself with
edges of the
container.
• Accepts several
services from the
community.
• Simplifies tasks.
a A point is added to the total score because education is < years.
Notes: AMD: Age-Related Macular Degeneration; OD: right eye; OS: left eye; TV: television; PIN: personal identification number.
PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS
139
140 M.-È. GERVAIS ET AL.

obtained written consent and administered measures specific to the study. During
the first visit, one of the two standardized cognitive screening tests was administered
(MMSE-Blind version or MoCA-Blind version). Given the similarity of certain items
in the two cognitive tests and potential cognitive interference between the two, the
second test was administered during the second visit (at least 1 week later) and the
order of assessment was alternated among participants. As part of her usual work,
the occupational therapist conducted a first functional assessment which included
an evaluation of activities of daily living using an adaptation of the Canadian Occu-
pational Performance Measure as well as observations of performance of specific
activities tailored to the client’s reported difficulties (e.g., using the phone or the
stove). The evaluation process is guided by the principles of the Human Develop-
ment Model-Disability Creation Process (Fougeyrollas, 2010), which is widely used
in the Quebec rehabilitation system, and lasts one to two sessions. The goals to be
included in the occupational therapy intervention plan were thereafter decided in
collaboration with the client. The length of interventions varied depending on the
goals and particular needs of clients. Interventions included a variety of techniques
including task modification, adaptations of the environment, training the client to
scan the environment more effectively and to use different parts of the retina, and
teaching and supporting the adoption of different devices.
During the last visit of the intervention, the occupational therapist adminis-
tered the Assessment of Life Habits (LIFE-H) (described below), and carried out
a functional assessment according to the usual protocol. After the final visit, the
achievement of rehabilitation goals was assessed by the occupational therapist.
Furthermore, based on her observations throughout the rehabilitation process, the
occupational therapist rated her own appreciation of the client’s cognitive function-
ing and its impact on the rehabilitation process (see Measures section for further
details). Although it would have been interesting to have a blind evaluator adminis-
ter the standardized tests to compare with the occupational therapist’s appreciation,
we chose a protocol which would represent clinical practice more closely where the
therapist is cognizant of tests results at the beginning of the therapy process.

Measures

The Mini Mental State Examination - Blind version (Reischies and Geiselmann, 1997;
MMSE-BV). The original MMSE was designed to allow clinical assessment of cogni-
tive status within the geriatric population. It can be used as a cognitive screening tool
(Folstein, 1975). The MMSE includes 11 questions assessing orientation, memory,
attention, language, and constructional praxis. The MMSE-BV is identical to the
regular MMSE, but tasks requiring the use of vision are removed. Specific norms
for individuals with visual impairment have been established (Busse et al., 2002).
The maximum score is 21, with a cut-off score of 15–17, depending on age and level
of education. With these thresholds, sensitivity (between 91 and 100%) and speci-
ficity (between 80 and 100%) are adequate. The instrument is known to have good
test-retest reliability (Busse et al., 2002).
 PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS 141

The Montreal Cognitive Assessment - Blind Version (Wittich et al., 2010; MoCA-
BV). The original MoCA was designed to detect mild cognitive impairment
(Nasreddine et al., 2005). It assesses the following functions: attention, concen-
tration, executive functions, memory, language, visuoconstructional capabilities,
abstraction, calculation, and orientation. According to the original normative study,
a score of 26 and above is considered normal (maximum number of points is 30).
This test is widely used, is translated into 29 languages and has good psychometric
properties: test-retest reliability is excellent (correlation coefficient = 0.92, p <
.001) and internal consistency is good, with a Cronbach’s alpha of 0.83 (Nasreddine
et al., 2005). In the version adapted for people who have visual impairment, items
that require vision are not administered (these items are not replace by other tasks).
In their study on the sensitivity and specificity of this version, Wittich et al. (2010)
found that the specificity of the measure is excellent, but the sensitivity is reduced.
To improve sensitivity, Wittich and colleagues recommend the use of a cutoff
score of 18 (the maximum score for this version being 22), which corresponds
to a proportional adjustment. One adaptation was made to the original protocol:
repetitions of the five-word list were allowed until the participant could recall all
five words at the initial retention stage to ensure complete encoding (the original
protocol suggests only two attempts - the MMSE protocol allows up to six attempts).
This adaptation allowed to more closely mimic what is done during occupational
therapy (e.g., a therapist ensuring a client has encoded instructions to use a visual
aid, at least in the short-term).
The Assessment of Life Habits (LIFE-H) (Noreau et al., 2002) is a standardized tool
which assesses a person’s degree of accomplishment of life habits (various daily activ-
ities and social roles), the type of assistance required (no assistance, assistive device,
adaptation, human assistance) and level of satisfaction regarding life habits. The
LIFE-H has been validated in various populations and in older adults specifically
(Desrosiers et al., 2004, Noreau et al., 2004). The short form contains 77 life habits
grouped into 12 categories: six measuring daily activities (nutrition, fitness, personal
care, communication, housing, mobility) and six measuring social roles (respon-
sibilities, interpersonal relationships, community life, education, employment and
recreation). In order to shorten the administration of the tool, categories measuring
education and fitness were not administered, leaving 67 items and 10 categories.
This instrument was used to document life habits performed with or without diffi-
culty, with or without human assistance, and with or without technical or assistive
aids. For each item, the LIFE-H generates an achievement score (level of difficulty)
and a score of required assistance. These scores are combined and weighted to derive
an accomplishment score: ( Scores × 10)/(number of applicable life habits × 9).
The total score for each life habit category ranges from 0 to 10 with a higher score
suggesting greater social participation. Satisfaction for each life habit is rated on a
Likert scale from 1 (very dissatisfied) to 5 (very satisfied) and averaged by domain.
Achievement of treatment plan objectives. The objectives recorded in the partici-
pants’ individualized treatment plans (available in medical records) were compiled
142 M.-È. GERVAIS ET AL.

(e.g., identifying food in the grocery store, reading mail, watching television). Fol-
lowing the last intervention session with the participant, all rehabilitation objectives
were rated by the occupational therapist with regards to their level of achievement
using the following scale: 0 = not achieved (unable to complete the tasks identified as
objectives at all or requiring substantial help); 1 = partially achieved (may complete
the task with difficulty/errors or less consistently or with minimal help); 2 = achieved
(able to complete the tasks independently, satisfactorily and consistently). Objec-
tives that were abandoned because they were impossible to reach received a rating of
0. Objectives that were abandoned for other reasons (e.g., loss of interest, change in
life situation) were not counted in the score. Time spent in occupational therapy for
visual impairment (number of sessions and hours of treatment) was also recorded.
Therapist’s perception of cognitive function and the impact of cognitive difficul-
ties on the rehabilitation process. Following rehabilitation with each participant, the
therapist rated her appreciation of each participant’s cognitive function using a
Likert Scale ranging from 0 to 2: (0) the participant did not display any signif-
icant cognitive difficulties; (1) the participant showed mild cognitive difficulties
that did not interfere with the proposed rehabilitation interventions; (2) the par-
ticipant showed cognitive difficulties significant enough to interfere with proposed
rehabilitation interventions; modifications to the usual treatment strategies were
needed.
To further document the impact of cognitive difficulties on the rehabilitation
process, participants’ medical records were reviewed (OT reports, reports of other
LVR specialists, contingency plans, progress notes) for any note pertaining to learn-
ing difficulties, problems with adjustment to therapy, any adaptations to therapy
made by the therapist or participant-initiated compensatory strategies observed
during LVR. An example of a therapist-initiated adaptation to therapy would be the
inclusion of reminders to help with the use of a technical aid, for example, writing
instructions in large letters beside a technical aid, or recording vocal instructions
with a recorder. An example of a participant-initiated compensatory strategy could
be the use of notes or touchable markers to remember how to use certain objects.

Results
Table 1 presents participant characteristics and clinical observations. Overall, all
participants obtained scores within the normal range for the MMSE and only one
participant (Participant 5) obtained a score below the cut-off on the MoCA. It should
be noted however that Participants 2 and 6 had a score below the cut-off on the
MoCA before a point was added due to their education level (less than 12 years).
Furthermore, five out of six participants required at least two repetitions to learn
the five-word list on the MoCA (Participants 2, 5, and 6 required two repetitions;
Participants 3 and 4 required three repetitions). All participants required at least
one semantic cue to recall the word list on the MoCA, and four needed a multiple
choice cue to retrieve at least one word (Participants 2, 4, 5, and 6). Despite the fact
that almost all final scores were within the normal range, the therapist observed that
 PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS 143

four out of six participants had cognitive difficulties significant enough to hinder the
rehabilitation process (Participants 1, 4, 5, and 6).
When examining Table 1 with visual analysis, there is no apparent link between
cognitive test scores on the MMSE or MoCA or the therapist’s appreciation of
cognitive difficulties and age, visual acuity, social support, or time spent in ther-
apy. Standardized test scores also seemed unrelated to the participant’s success in
achieving rehabilitation objectives. The therapist’s appreciation of cognitive func-
tion, however, was clearly linked to success in reaching rehabilitation goals: those
identified as having no significant cognitive issues (Participants 2 and 3) achieved
all of their objectives whereas those identified as having difficulties significant
enough to hinder the rehabilitation process (Participants 1, 4, 5, and 6) had more
unachieved objectives and more adaptations to therapy (e.g., use of reminders,
adapting electronic aids, simplifying objectives). On the other hand, those observed
as not having cognitive difficulties by the therapist (Participants 2 and 3) tended to
use self-initiated compensatory strategies (e.g., taking notes, counting pills) suggest-
ing good self-awareness and capacity to adapt to their limitations. Individualized
results for each participant are presented below.
Participant 1. At the end of LVR, the participant had reached four of her nine
objectives. Three objectives were partially achieved (connecting an electrical plug,
proofreading, recreation reading - magazines) and two goals were not achieved
(using the internet, playing scrabble on the computer). Her scores on the MoCA-BV
and the MMSE-BV were within the normal range (19 and 21, respectively). How-
ever, on the Likert scale assessing the therapist’s appreciation of cognitive function,
a rating of 2 was given indicating that this client had difficulties which hindered
learning during therapy sessions. The therapist’s progress notes indicated that dur-
ing the treatment process several repetitions were necessary for the participant to
be able to use new visual technical aids: for example, she had trouble using the new
devices to use the computer despite the fact that she had been using computers until
2011 and had been able to complete bank transactions over the internet in the past.
In addition, the participant exhibited difficulties in comprehension of the instruc-
tions to use the technical aids. She showed little initiative in exploring the proposed
devices (e.g., using a digital book player) despite manifesting some interest in using
it at least initially. The initial goals required simplification (e.g., therapist taught only
shortcut keys for text amplification). Furthermore, the therapist introduced visual
and/or audio-recorded reminders to assist with the integration of taught strategies
(e.g., reminders on how to use the digital book player), but the participant did not
use the reminder efficiently (e.g., reducing speed of digital reader to avoid nausea).
It is possible the participant was not as motivated to use the devices as was initially
expected.
Following rehabilitation, in terms of life habits, the participant still reported dif-
ficulties in personal care but performed these activities independently. She was able
to communicate with human assistance (e.g., help to read certain material) and she
reported managing her finances independently using technical aids. Recreation-
related activities were carried out with difficulty and with technical aids. Despite
144 M.-È. GERVAIS ET AL.

the need to use technical aids or human assistance for the accomplishment certain
life habits and despite remaining problems, she felt satisfied with her overall func-
tioning in her life habits, except for the use of the computer for which she was more
or less satisfied.
Participant 2. At the end of LVR, the participant had achieved all her objectives.
She obtained results within the normal range on cognitive tests (MOCA-BV = 18;
MMSE-BV = 19) although the score on the MoCA was close to the cut-off. The
therapist did not perceive any cognitive difficulties during the rehabilitation process
except occasional digressions during conversations. The participant however, com-
plained of a declining memory and reported she sometimes had word-finding diffi-
culties and occasionally forgot the topic of a conversation. She seemed well aware of
these issues and reported using strategies to counter these perceived cognitive issues,
including taking notes to remember information or tasks to accomplish (e.g., stow
manuscript notes and retrieve them when needed). The therapist noted a good level
of self-awareness and capacity to compensate for possibly emerging cognitive diffi-
culties. She had relatively simple rehabilitation goals and learned how to use a video
magnifier without difficulty.
With regards to the completion of her life habits following rehabilitation, the
participant reported carrying out the activities related to nutrition with difficulty,
but without assistance. She could communicate without difficulty and without help.
Recreation activities were achieved without difficulty but with human assistance.
She reported being satisfied with her general level of functioning.
Participant 3. Following rehabilitation, this participant achieved all six of her
objectives. She obtained scores within the normal range on the MoCA-BV and the
MMSE-BV (18 on both tests) although the score on the MoCA was close to the
cut-off and on the memory subtest of the MoCA, three repetitions were required to
remember the list of five words. The therapist attributed a score of 0 on the Likert
scale indicating no significant cognitive difficulties interfering with learning, despite
the fact that a caregiver had reported that the participant sometimes had memory
lapses. The therapist noted that even before the rehabilitation process, the partic-
ipant was already using good strategies to compensate for her visual impairment
(placing markers on containers; using adapted containers for eating; counting her
pills). She also presented openness to community services. Following rehabilitation,
the participant reported achieving her activities related to communication easily and
without help. She was satisfied with her functioning regarding all her life habits.
Participant 4. Upon completion of rehabilitation, this participant had achieved
five out of his six objectives. The only partially reached goal was finding and applying
ways to obtain satisfactory lighting in his home. His scores on the MoCA-BV and the
MMSE-BV were within normal range (20 and 19, respectively). However, it should
be noted that on the memory subtest of the MoCA, three repetitions were required
to remember the list of five words. The therapist’s rating of 2 suggests that this partic-
ipant may have had cognitive difficulties despite normal test scores. Indeed, during
rehabilitation, the therapist noted that the participant had problems with focusing
his attention on the task at hand, and that he had trouble understanding how to use
 PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS 145

new assistive devices (e.g., forgot the first button to push on a digital book player and
thought the device was broken, did not use reminders effectively). The participant
also had difficulty organizing himself in order to find information regarding one of
the visual aids. He had problems implementing the strategies taught during therapy
and did not use reminders effectively. On the other hand, the participant showed
patience and motivation to learn throughout the rehabilitation process. Following
rehabilitation, the participant reported performing all of his life habit-related goals
without difficulty or help, and was satisfied with his life habits.
Participant 5. This participant achieved four out of nine objectives, two were
partially met (using the phone and decoding phone numbers) and three were not
achieved (writing short notes, reading short texts and watching television). She
obtained a score of 17 on the MOCA-BV, which is below the normal range (cut-off
of 18; with difficulty on the memory subtest). However, on the MMSE-BV the par-
ticipant was within the normal range with a score of 19. The therapist rated a score
of 2 on the Likert scale because cognitive difficulties were observed during the reha-
bilitation process. The participant had difficulty remembering instructions for the
use of a device, either for its simple or more complex functions (e.g., using a digital
book player or using a programmed dialing key on the telephone). Participant 5 also
abandoned certain objectives (including writing short notes and decoding telephone
numbers) because she found them too difficult to achieve after several attempts. The
therapist had to simplify the goals and methods of intervention in order to facilitate
the implementation of certain life habits. The participant decided on her own to
abandon certain life habits, including the use of the stove, as she tended to forget to
turn it off.
Concerning the performance of her life habits following rehabilitation, she
reported having difficulty with nutrition-related activities and required assistance in
this area. She could communicate without difficulty or assistance. She reported exe-
cuting her financial responsibilities with difficulty, even when using technical aids.
She was nonetheless satisfied with the majority of life habits addressed in rehabili-
tation, despite the difficulties that remained and the need to sometimes use assistive
devices or human assistance. She remained more or less satisfied with the use of her
television.
Participant 6. Following rehabilitation interventions, the participant achieved six
out of eight objectives. Unachieved goals were related to programming of her phone
and entering of her personal identification number (PIN) at the bank. She obtained
results within normal range on cognitive screening tests (MoCA-BV = 18; MMSE-
BV = 19). The score on the MoCA is close to the cut-off and difficulties were
observed when she was asked to recall the word list on the MoCA. The therapist
attributed a score of 2 on the Likert scale, noting cognitive difficulties significant
enough to influence the rehabilitation process. Notes reported in her file highlight
that during the rehabilitation process, she had word-finding difficulties, her lan-
guage was imprecise and she reported difficulty retaining certain types of informa-
tion, such as phone numbers. Repetitions were also necessary to enable the learning
146 M.-È. GERVAIS ET AL.

of a closed-circuit television system. However, in a familiar situation and at a suit-

able rhythm, she was able to memorize the operations required for using a technical
aid for sewing (needle threader) and was eventually able to complete cross-words
with the closed-circuit television system. She tended to avoid situations involving
greater pressure which led to more anxiety, such as typing in her bank PIN in a
real situation (where ATM machines or payment terminals vary greatly and are not
adapted for persons with visual impairment). The therapist had to simplify the ini-
tial rehabilitation objectives and introduced visual and auditory reminders to assist
with learning. Following rehabilitation, the participant was generally satisfied with
her functioning for most of her life habits. She reported that she was able to com-
municate with difficulty but without assistance. She participated in activities related
to nutrition, responsibilities (financial), as well as recreation without difficulty or
human assistance.

Discussion
The present study aimed first to evaluate the consistency between two standard-
ized cognitive screening tests, the MoCA and the MMSE “Blind” versions, and the
therapist’s observations about cognitive functioning of elderly individuals during
rehabilitation for visual impairment. Another objective was to explore whether cog-
nitive functioning influenced the rehabilitation process and was linked to the per-
son’s satisfaction with their different activities of daily living. All participants had
scores within the normal range with the MMSE. All but one (Participant 5) had
scores within the normal range on the MoCA. Scores with both instruments were
unrelated to factors such as age, severity of visual acuity, and intensity or length of
therapy. The therapist who carried out LVR interventions, however, perceived cog-
nitive difficulties significant enough to hinder the rehabilitation process in four out
of six participants.
Our data suggest that there is no clear relationship between cognitive status and
adaptations needed during therapy, achievement of rehabilitation objectives, or abil-
ity to perform life habits. Of importance, regardless of cognitive functioning, all par-
ticipants exhibited good satisfaction in their life habits despite persisting limitations
at the end of LVR, even when there remained a need for human or technical assis-
tance to perform certain life habits (see Figure 1). For one participant with a score
lower than the cut-off on the MoCA, the cognitive screening test score could perhaps
have helped the therapist anticipate a relatively more complex rehabilitation process
and plan for additional resources or adaptations. On the other hand, for participants
with scores close or higher than the cut-off, the screening test scores did not help
to predict smoother or more complex rehabilitation processes. Indeed, participants
with identical MMSE or MoCA scores had quite heterogeneous profiles in terms of
number of objectives achieved and in terms of therapist-initiated adaptations dur-
ing therapy. The therapist’s perception of cognitive functioning of the participants,
however, was more clearly linked to achievement of rehabilitation objectives and to
 PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS 147

Figure . Participation and satisfaction scores for different life habit categories on the Assessment of
Life Habits Instrument (LIFE-H) for each participant (for participation, scores range – with higher
scores suggesting greater social participation. Satisfaction is scored on a Likert scale from -very dis-
satisfied to -very satisfied).
148 M.-È. GERVAIS ET AL.

the use of adaptations to therapy: individuals rated as having cognitive difficulties

by the therapist more often presented unachieved or abandoned objectives, and
required more adaptations to therapy, such as reminders or simplification of devices
or strategies.
The inconsistency between the screening test results and the therapist’s appreci-
ation of cognitive functioning suggests that standardized tests may not be quite as
informative as we would wish them to be in order to guide the planning of rehabil-
itation for visual impairment in older adults. The MMSE particularly, yielded quite
homogenous scores across participants and did not pick up difficulties where the
MoCA did, a result that corroborates the literature on this instrument (Hoops et al.,
2009; Nasreddine et al., 2005) since the MMSE is designed to screen for demen-
tia. The MoCA is known to be more sensitive than the MMSE to milder forms of
cognitive impairment, and could be an interesting tool if cognitive issues are sus-
pected, but the use of a more stringent cut-off score could be considered (e.g., less
than 17) and further researched. Of course, contrary to the cognitive tests which
were administered at the beginning of treatment and focus on specific functions,
the appreciation of the therapist was acquired throughout the intervention period
and in various situations observed in the participant’s own living setting. It is possi-
ble that therapists are able to pick up on more subtle aspects of cognitive functioning
not measurable by standardized tests. Participant 1’s results are a good example: she
obtained the highest score on the MMSE (21) and one of the two highest scores
on the MoCA (19) yet she displayed several difficulties integrating the use of new
electronic visual aids. Her memory subtest scores on the MMSE and MoCA did
not suggest retention or recall issues, suggesting that her difficulties stemmed from
different cognitive domains, perhaps more linked to executive functions and/or to
decreased motivation. Indeed she seemed to lack spontaneous motivation to explore
the devices and had difficulty solving problems encountered during rehabilitation,
suggesting suboptimal self-initiation or mental flexibility. It should be underscored
however that what the therapist may perceive as cognitive issues may also be caused
by fluctuations in motivation, interest in new technologies, the complexity of the
rehabilitation objectives, or lack of environmental support.
Although it may be intuitive to think that LVR would be complicated in the
presence of significant cognitive difficulties, our results and those of others suggest
that the relationship between the two is by no means simple. In a study of 91 older
adults with macular disease, Whitson’s team (2011) found that about 19% had
cognitive impairment as evaluated with the Telephone Interview for Cognitive
Status - modified (TICS-m), a standardized cognitive test derived from the MMSE
devised to be administered over the phone. Much as in the present study, baseline
cognitive status did not predict rehabilitation outcomes. Interestingly however,
in Whitson’s study the worst functional trajectories were found for persons with
marginal cognitive difficulties, as opposed to those without impairment or with
more severe cognitive impairment. The authors hypothesized that rehabilitation
professionals tend to spontaneously modify their interventions when cognitive
impairment is obvious, but may not do so when it is more subtle. Thus, patients
 PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS 149

with marginal cognitive difficulties may not be receiving care specifically tailored to
their needs, for example, with appropriate adaptations to therapy and involvement
of the social support network. The present results corroborate Whitson’s (2011)
findings as most of our participants had scores close to the cut-offs yet several
seemed to have difficulty implementing the strategies taught by the therapist. Our
results bring further evidence that if simple adaptations are made to therapy, such as
including reminders, simplifying objectives, repeating information, and simplifying
the use of technical devices, positive results are to be expected along with good
levels of participation and satisfaction in life habits on the part of clients. The
latter conclusion is completely in line with a LVR program devised by the Whitson
team specifically for older adults with low vision and mild cognitive impairment
(Whitson et al., 2013). Indeed these authors propose a program which incorporates
three main adaptations to standard LVR in these particular clients: (1) intensifying
therapy (training with a therapist repeated twice a week for 6 weeks), (2) address-
ing a maximum of three rehabilitation objectives, and (3) involving an informal
companion. Preliminary data with this program in twelve patients were found to
be encouraging (Whitson et al., 2013), yet this type of program is probably more
resource-consuming than the treatment-as-usual services offered to clients. In our
study, we obtained favorable results despite not necessarily intensifying treatment
nor involving systematically a significant other. Time spent in therapy or number of
sessions was not linked to cognitive status (measured with tests or by the therapist)
and good results were obtained in relatively little time in some participants, for
example, 14–17 h of therapy or six to eight sessions, while one participant displayed
relatively poorer results even with 15 sessions and more than 30 h of therapy.
Specific subtests of the MoCA or the MMSE were not particularly informative.
For example, on the memory subtest on the MoCA, almost all participants required
two repetitions of the five-word list for adequate initial retention of the words. Fur-
thermore, all participants at least required semantic cues to remember one or more
words, and five out of six required multiple choice cues (which suggests even weaker
retention) for one or more words. The person who had the most difficulty recalling
the five-word list on the MoCA was Participant 2 (delayed recall score of 0/5 and
multiple choice required to recall 4/5 words despite two initial repetitions of the
word list) yet she was perceived by the therapist as functioning well and had no par-
ticular difficulty with learning strategies during rehabilitation. Whitson et al. (2012)
found a relationship between a low score on a 10-word memory test (two words or
less) and worse vision-related outcomes in rehabilitation. It is possible that the test
they used was much more sensitive to semantic memory impairment compared to
the MoCA or MMSE memory subtests. Even in the absence of such test results, ther-
apists could pay increased attention to encoding and retention of instructions during
LVR with older adults, for example, by repeating information, providing both audio
or appropriate visual reminders and cues, and involving family members to ensure
optimal encoding of information (e.g., family members helping a client practice the
use of a new device, but letting the client operate the device himself to favor learn-
ing and retention). Wittich and colleagues (2016) showed that giving simple and
150 M.-È. GERVAIS ET AL.

short instructions and allowing simple repetition (practice) of tasks could increase
the success of elderly individuals with low-vision in using hearing aid devices.
Another interesting scenario was that presented by Participant 2 who obtained a
score on the MoCA very close to the cut-off. In fact her total score was 17 (below cut-
off) but one point was added to her total because of her level of education (less than
12 years). This particular participant self-reported cognitive issues relating to mem-
ory, word-finding difficulties and occasional problems with maintaining a conversa-
tion topic. It is possible that this participant presented mild cognitive difficulties that
could perhaps have been measurable if a more elaborate neuropsychological battery
had been administered. Yet, this participant also displayed noticeable self-awareness
and ability to find and apply efficient strategies (e.g., use of notes) to help her carry
out her life habits in a satisfactory manner, evidence of efficient metacognitive and
self-regulatory strategies. Such self-awareness was also noted in Participant 3 who
found various ways to adapt to her visual impairment (placing and elastic on certain
pill containers to recognize them easily; eating meals in a plastic container where she
can more readily feel the edges) and potential fluctuations in cognition (counting
pills to make sure she has not forgotten any). These results illustrate the large range
of variability between objective cognitive test results and functioning, where some
individuals learn to be very efficient at compensating for potential cognitive decline,
perhaps suggesting greater cognitive reserve in these individuals (Tucker & Stern,
2011). Reinforcing the client’s self-awareness and self-initiated compensatory strate-
gies could prove to be particularly an important part of therapist approach with this
population.
In this study, cognitive functioning was seemingly unrelated to visual acuity nor
to age. Thus, it is probably erroneous to presume that older individuals and/or those
with more severe visual impairment will less likely benefit from rehabilitation, even
in the presence of suspected cognitive decline. Hagerman and colleagues (2007)
arrive to the same conclusion. They found that even patients with markedly lower
scores on the MMSE (i.e., less than 21, thus indicating moderate cognitive impair-
ment) improved when low-vision devices were introduced during rehabilitation.
The authors underscore that some regulatory bodies (e.g., Medicare in some US
states) impose restrictions to access to LVR services for persons who have cognitive
impairment (e.g., exclude persons with a score lower than 21 on the original version
of the MMSE), thus impeding access to rehabilitation services because of suspected
lower cognitive status. In our study, four out of five participants had scores of 19
or less on the MMSE yet all made notable progress during rehabilitation, achieved
at least four rehabilitation objectives, and exhibited levels of participation in dif-
ferent life habit categories that were satisfactory to them (Figure 1). Clearly, a test
score is not sufficient to make the assumption that a person will not benefit from
LVR: cognitive reserve, client-initiated strategies, client motivation, social support,
environmental stressors and constraints, the client’s willingness to accept assistance,
openness to new technologies and the realism of objectives must all be considered
to evaluate the potential success of rehabilitation.
 PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS 151

Of note, regardless of the results of rehabilitation, participants showed good sat-

isfaction with their life habits, and this was the case even if human assistance or
technical assistance were required to perform life habits. These results are in line
with those of Renaud (2013) who examined the relationship between social partici-
pation and level of satisfaction of older adults with visual impairments. Much like in
the present study, Renaud and her colleagues highlighted that despite restrictions,
older adults are generally satisfied with their level of participation, although perhaps
less so with habits linked to entertainment, communication and mobility. Interest-
ingly, Good (2005) reported that older individuals aged 85 years or less with visual
impairment rated themselves less satisfied, less active and less independent as their
sighted peers, however, persons 85 years and older with visual impairment did not.
The author suggests this group might show more hardiness and have a more positive
appraisal of their performance. This is also in line with earlier qualitative research by
Kleinschmidt (1999) suggesting that many older adults with vision loss are resilient
and adapt well building on prior life experiences and adequate internal and external
resources.
This case series study is limited by its small sample size thus restricting the gener-
alizability of the results. The study did not include persons with diagnosed dementia
for whom LVR may well be more complex and for whom standardized tests could
perhaps have been more informative. Furthermore, results were possibly influenced
by the subjective evaluation of the therapist involved. Also, the adaptation made
to the MoCA protocol allowing more than two repetitions of the word list possi-
bly led to an underestimation of cognitive deficits as some participants might have
had lower scores if no repetitions had been allowed. A more comprehensive bat-
tery of neuropsychological tests, more sensitive to cognitive decline, could have
yielded clearer results and independent evaluators could have added objectivity to
the administration of the standardized screening tests. Participants’ time spent in
therapy also varied for every individual which may also have influence the results.
The present study has several strengths however that merit attention. This case series
has the advantage of being closely representative to what is currently done in clin-
ical practice, and has brought light on qualitative aspects that have not been previ-
ously documented in larger samples, such as specifying the nature and number of
rehabilitation objectives and their level of achievement through rehabilitation, going
into details of observations during cognitive testing and documenting therapist and
client-initiated adaptations.
Future research could investigate how social support available to the participant
may supplement occupational therapy interventions for visual impairment. Indeed,
attention or assistance from a spouse or child caregiver can help clients to integrate
rehabilitation training strategies in the form of reminders. Future studies are also
needed to evaluate whether systematically adapting therapy to the older adult will
yield more positive outcomes. Another avenue for future research may involve the
interaction between visual impairment, cognitive decline, and psychological symp-
toms such as depression and anxiety. Furthermore, research could also investigate
152 M.-È. GERVAIS ET AL.

if willingness and interest to adopt new technologies is sometimes a barrier to LVR

in the elderly.
In conclusion, we found that the use of cognitive screening tests such as the
MMSE-BV and the MoCA-BV provided limited guidance to anticipate a more or
less complex rehabilitation process in the context of low-vision in the elderly. A vari-
ety of other factors such as self-awareness, motivation, help of significant others, and
anxiety might influence the outcomes. If they are used however, the results of tests
are possibly more informative if clearly low scores are found. More importantly, even
clients with seemingly measurable cognitive difficulties benefit from rehabilitation
and are satisfied with their life habits after LVR. Our results clearly show that mild or
even moderate levels of cognitive difficulties do not preclude rehabilitation for even
severe visual impairment in elderly persons, and does not entail significantly longer
or more intense rehabilitation. Most elderly clients will benefit from simple adap-
tations to therapy such as simplification of objectives, strategies or use of devices
and use of reminders. Since up to a third of elderly clients will potentially have at
least mild cognitive impairment (Hagerman et al., 2007), LVR programs could con-
sider systematically including such adaptations to optimize care for elderly patients
as these are rather easy to implement without significantly complicating or length-
ening treatment.

Declaration of interest
The authors report no conflicts of interest. The authors alone are responsible for the content and
writing of the article.

Acknowledgments
The authors would like to thank Danielle Giguère, Mireille Prémont, Manon Lachance, Johanne
Picard, Caroline Charest and Louise Martel who contributed to this study. We thank Simon
Beaulieu-Bonneau and Danielle Tessier for reviewing the text. Finally we thank the six partici-
pants, and the Institut de Réadaptation en Déficience Physique de Québec for its financial support.

Funding
This study was supported by a grant from the clinical research support program of the Institut de
réadaptation en déficience physique de Québec.

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