aer conference 2012 visual anomalies from brain injury and rehabilitation strategies

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AER CONFERENCE 2012 VISUAL ANOMALIES FROM BRAIN INJURY AND REHABILITATION STRATEGIES Paul Koons, M.S., C.O.M.S., C.L.V.T., C.B.I.S. Email: [email protected]

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Paul Koons, M.S., C.O.M.S., C.L.V.T ., C.B.I.S . Email: [email protected]. AER CONFERENCE 2012 Visual Anomalies from Brain Injury and Rehabilitation Strategies. Background/Experience. Pa. College of Optometry /Salus Univ 1999 Graduate studies - PowerPoint PPT Presentation

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Page 1: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

AER CONFERENCE 2012VISUAL ANOMALIES FROM BRAIN INJURY

AND REHABILITATION STRATEGIES

Paul Koons, M.S., C.O.M.S., C.L.V.T., C.B.I.S.

Email: [email protected]

Page 2: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Background/Experience Pa. College of Optometry /Salus Univ 1999

Graduate studiesOrientation & Mobility , Low Vision Therapy

Experience: NYC Lighthouse International State Blind Rehab agencies (Pa, CO, Va) Presently Veteran’s Affairs – Polytrauma

center blindness and vision loss specialist (Palo Alto & currently Richmond)

Page 3: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Goals of Presentation Define Polytrauma with emphasis on vision loss Discuss Mechanism of Injury causing Brain Injury Types of visual deficits / anomalies Rehabilitation Timelines Multi-Discipline therapies addressing deficits

Part of Team: MD, OD, PT, KT, OT, SLP, RT, Psych, RN, LPN, MSW Case studies Resources Audience goal - think about your networks for addressing

brain injury and visual deficits

Page 4: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Disclaimer statement This presenter has no financial interest

in any of the makes, models of rehab equipment, devices, sunwear or assessment tools

Page 5: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Brain Injury: TBI – an acquired brain injury caused by an

external physical force, resulting in partial functional disability or psychosocial impairment, or both, adversely affecting educational performance.

TBI – Traumatic Brain Injury (MVA, Fall, GSW, IED blast)

ABI – Acquired Brain Injury (Stroke, Brain Tumor, Anoxia, Hypoxia, Seizures, Blood clots)

Page 6: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

TBI Severity and PrognosisIndex Mild Moderate Severe

GCS 13-15 9-12 <8

LOC <30 min <6 hours >6 hours

Duration of PTA

0-24 hours 1-7 days >7 days

Permanent neurologic & neuro-psychological sequela

Likely none Likely some but are often quite functional

Likely to have severe deficits

Page 7: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Severity of Brain Injury Mild TBI / Concussion – Loss of

Consciousness less than 30 minutes (or NO loss)- Post Traumatic Amnesia for less than 24 hours. Post Concussion Symptoms

Moderate TBI – Coma more than 20-30 minutes, but LESS than 24 hours. Some long term problems in one or more areas

Severe TBI – Coma longer than 24 hours, often lasting days or weeks, Longer term impairments

Page 8: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Estimates of TBI Severity

Mild TBI / Concussion – up to 80% of all cases.

Moderate TBI 10% - 30%

Severe TBI 5% - 25%

According to Brain Injury Assoc of America

Page 9: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Traumatic Brain Injury in America Not “just” a VA problem

Polytrauma highlighted because of high incidence of occurrence in Iraq / Afghanistan (OEF/OIF)

Relevance to community services (Brain injury Association of America)1.4 – 1.7 million Americans sustain TBI Annually

○ One every 21 seconds700,000 Americans experience stroke annually

○ One every 45 seconds

Page 10: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Annual incidence of TBI per Age group

0-4 years old (1121 per 100,000 cases) 15-19 years old (814 per 100,000 cases) 5-9 years old (659 per 100,000 cases) 75 years and older (659 per 100,000 cases)

Often times any brain injury during initial years not realized until later years

○ According to Brain Injury Assoc of America

Page 11: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Highest incidence of death due to TBI

75 years and older (51 per 100,000) 20-24 years old (28 per 100,000) 15-19 years old (24 per 100,000)

-According to Brain Injury Assoc of America

Page 12: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Multiple TBI Risk Factors

After 1 TBI, the risk for a 2nd is 3x greater

After 2 TBIs, the risk is 8x greater

Brain Injury Association of America

Page 13: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Brain Injury Recovery timeline General 2 Year “Window” for Recovery

Try to “Estimate” degree of recovery in initial 6 months since Injury

Severity of Brain Injury a factor, also Anoxic/Hypoxic Brain Injury may kill off more brain cells unable to regenerate

Bottom Line – Recovery has been seen several years later, but initial 2 year timeline is a “benchmark”

Page 14: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Ophthalmologic and Optometric Interventions

Ocular Health Exam Prescription of appropriate corrective

lenses Use of occlusion – complete or partial Prisms – yoked, Fresnel Medical and surgical intervention when warranted Optometric plan of care for ocular motor,

accommodative dysfunctions

Page 15: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Polytrauma

Polytrauma is currently defined as multiple injuries of which one (or a combination) is life threatening.

Co-Morbidities associated with TBIVision, Hearing, Physical, Cognitive,

Behavioral, PTSD, Sleep, etc

Page 16: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Mechanism of Injury Motor Vehicle Accident Sports Concussions Falls Physical Altercations Stroke, Brain Tumor (multiple TIA’s) Gun Shot Wound (could be self-inflicted) Anoxia / Hypoxia Cranial Depression to relieve brain swelling

prior to Cranioplasty procedure

Page 17: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Bullet Wound: Entering Left Frontal-Temporal area,

Passing through parietal, midline into Right Occipital areaPossibly resulting in:

Contre coupe: Motor Vehicle Accident, trauma etc.

Possible watershed effect: damage to frontal lobe,Occipital lobe, extensive bleeding, extensive swelling etc

Haemorrhage: Parietal/Temporal: Specific site indicative of stroke, Frontal: typical blunt object traumaOccipital: Tumour

Page 18: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Improvised Explosive Devices (IEDs)

Page 19: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

IED Blast

• “Global” damage to brain and body• Described as “PRESSURE” Wave • “Torsional” effect or twisting of brain within skull• IED's also cause damage due to projectile bomb

fragments, debris and individual being ‘thrown’• Penetrating vs. non-penetrating injuries

Page 20: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Polytrauma Veterans Affairs

5 Main Polytrauma VA Hospitals in U.S.A.

Tampa, FloridaMinneapolis, MNPalo Alto, CARichmond, VaSan Antonio, Tx

Page 21: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Richmond VAMC Population (Mechanism of Injury)

since 2007

0

10

20

30

40

50

60

70

Blast/ExplosionVehicle

Bullet

Other

Page 22: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Richmond TBI rehab Population (Injury Location)*since Sept. 2007

0102030405060708090

IraqAfghanistanStatesideOther

Page 23: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Some Emerging Characteristics of Polytrauma Patients They are a unique population with unique,

long term issues They may not be good self-advocates Many are young and have full lives ahead They are “tech-savvy” They may not want services Most have family involvement and

maintain military culture

Page 24: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Most commonly reported visual symptoms related to TBI Headaches Diplopia / double vision Vertigo / Vestibular issues Asthenopia

Weakness or fatigue of the eyes, usually accompanied by headache and dimming of vision (may affect training in am / p.m.)

Accommodation - Inability to focus Movement of print when reading Difficulty with visual tracking and fixations Photophobia / Photosensitivity (night glare)

Page 25: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Site of Lesion

Page 26: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Visual Pathway - numbers indicate how lesion affect visual field(s)Red/Blue = image seen Gray = blind area

Page 27: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Left Vs Right Brain FunctionsLeft Brain Functions Right Brain Functions  uses logic

detail orientedfacts rulewords and languagepresent and pastmath and sciencecan comprehendknowingacknowledgesorder/pattern perceptionknows object namereality basedforms strategiespracticalsafe

  uses feeling"big picture" orientedimagination rulessymbols and imagespresent and futurephilosophy & religioncan "get it" (i.e. meaning)believesmusicFacial recognitionspatial perceptionknows object functionfantasy basedpresents possibilitiesrisk taking

Page 28: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Visual Anomalies of Brain Injury

Binocular dysfunction

Convergence Accommodation Saccadic/Pursuit

Ocular motorFixation

Visual Field Loss often seen:

Quadranopia Hemianopia macular sparing? General Peripheral loss

Page 29: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Methods to create success and independence through rehabilitation

1. “Fix / Improve Vision” – vision therapy or surgery

2. Use devices/lenses to improve vision (Magnifiers, Telescopes, Rx, Readers, Prisms, white cane)

3. Compensatory Strategies (eccentric fixation, scanning to blind visual field, place reading stand in better visual field)

Page 30: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Role of Vision SpecialistConsultative for Mild TBI patients:

performs diagnostic screening as needed and requests referral to the appropriate Eye specialist

provides recommendations for use of optical and non-optical devices to the other therapies;

monitors client’s level of visual functioning and provides intermittent screening

provides intermittent follow-up services

Page 31: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Role of Vision SpecialistInterventional Therapist/ moderate to severe TBIs

Provides daily intervention as per recommendation of the evaluating eye specialist and based on an established plan of care – duration,

Frequency of treatment and functional goals are pre-established prior to commencement of treatment

Progression and discharge from this service will be based on outcome and/or discharge from facility

Provide follow-up plan (use of readers, visual search, compensatory strategies)

Page 32: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Intervention Strategies Implemented by Vision Specialists Follow-up education and training in use

of prescribed corrective lenses Training and education on the use of

occluders and prism glasses to promote independence and safety during completion of ADL functions

Education on use of appropriate glare remediation

Page 33: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Intervention Strategies

Graded static and dynamic training to improve use of an organized and systematic scanning strategy

Training in the use of non-optical aids Orientation and mobility training

Page 34: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Intervention Strategies Manipulation of the environment a. reduction of background pattern b. use of adequate illumination c. increase in background contrast d. anchoring and boundary marking

strategies

Page 35: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Intervention Strategies Environmental modification to improve

awareness of missing visual space I.e.: bed placement to improve

awareness/scanning to auditory stimuli – hallway

I.e.: Place reading stand and material into/out of remaining visual field

Page 36: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Screening and Assessment Process

Vision Program

F/U

SLP/OT/PT Intervention

Page 37: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Glossary Accommodation Version

SaccadePursuit

Convergence Divergence Visual Fields Photosensitivity

changizi.wordpress.com

Page 38: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Research articles on Binocular Dysfunctions in TBI population

(military & civilian) Stelmack et al., 2009 (all levels of TBI in Hines VA hospital)

47% accommodative disorders 28% convergence insufficiency

Brahm et al., 2009 (all levels of TBI in Palo Alto VA hospital) 39.6% of accommodative insufficiency 42.6% of convergence insufficiency

Goodrich et al, 2007 (all levels of TBI in Palo Alto VA hospital) 21.7% had accommodative dysfunction 30.4% had convergence insufficiency

Ciuffreda et al., 2007 (Civilian, TBI rehabilitation) 41 % had accommodative dysfunction 42.5% had convergence insufficiency

Lew et al., 2007 (mild TBI) 21% accommodative insufficiency 46% convergence insufficiency

*all patients diagnosed in Optometric clinics within 3 months post trauma

Page 39: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

RIC Eye/TBI Clinic n=100 (2007-2009)Most Common Vision Disorders following TBI

Photosensitivity 34% Convergence Insufficiency 31% Saccadic Dysfunction 24% Dry Eye 23% Accommodative issues 18% Tropia (Eye Turn) 13% Visual Field defects 10%

*research design was conservative as these are primary dx but many of these overlap such as photosensitivity and accommodation

Page 40: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Accommodation Definition: ability to focus near and distant targets Measure Accommodation monocularly (diopter) Our eyes ‘bending’ power

Page 41: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Rehab strategies for Accommodation insufficiency

Page 42: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Ms. V Visual Dysfunctions

28 yr old with left Sylvian fissure AVM embolization left cerebral hemisphere ischemia

Accommodation insufficiency Reduced near point of convergence Saccadic dysfunction Dry eye Floaters OS per patient Photosensitivity

Page 43: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Reading with +/- power flipperscan be performed monoc. / binoc.

Page 44: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Hart Chart Activities (Saccades and Accommodation therapy)

Page 45: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Version / Eye movement Definition: smooth eye movements in the same direction

Saccade - efficient eye movement from one fixation point to another

Pursuit - two eyes ability to follow a target

Fixation-eyes’ ability to stop on an object and bring it into focus (fixate and focus)

Page 46: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Large and Small Saccades

Page 47: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Large Visual Saccades

Page 48: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Reading with small visual saccades

Page 49: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Rehab strategies for SaccadesDevelopmental Eye Movement (DEM)Test A + B = C (time measured)

Page 50: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Saccadic Reading Exercises

Page 51: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Wayne Saccadic Fixator

Page 52: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Rehab strategies for SaccadesHTS (Home Therapy System)

Page 53: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Rehab strategies for Ocular motor issues (Versions)

Page 54: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Vergence Eye MovementDefinition: smooth eye movements in opposite directions

Types:

Convergence and divergence

Strabismus: phoria (tendency to…) tropia (fixed).

Can be subtle or intermittent, dependent on gaze, fatigue, distance

www.petsadrift.com/grfx/crosseyed.jpg

Page 55: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Rehab strategies for Convergence/Divergence

Page 56: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Brock string for Convergence & Divergence - may include fusional prisms

Page 57: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Vectogram activity for Convergence / Divergence

Page 58: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Neurological Field Loss Strategies

Page 59: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Reading with R hemianopia

Page 60: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Reading with Left Hemianopia

Page 61: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Brahm et al., 2009 & Dougherty et al., 2010Visual field loss testing is recommended for

patients with a history of TBI

Page 62: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Visual Field Loss Accurately Assess Visual Fields Monocularly Confrontation, Finger counting ARC Perimeter / Hand held disc perimeter Goldmann, Humphries, Octopus (eye clinic) Educate Patient and Family! Show best use of remaining field placement Establish full perimeter scan (overshoot) or

staircase visual search methods Increase complexity of environments, reducing

cues

Page 63: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Visual Search & Scanning with Visual Field Loss

Chedru et al., 1973 Ishiai, et al., 1987

○ Meienburg, et al., 1981 Gassel et al., 1963

Recorded eye movements & visual search in TBI patients with hemianopia

Patients paradoxically concentrated on the blind side (compensation strategy)

Patients with additional neglect/inattention lacked this compensation strategy

Page 64: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Scanning Training with Hemianopia

Dr. Josef Zihl, 1988Trained 30 hemianopes (w/out inattention/neglect)Practice large saccades into blind fieldVisual search field increased 10-30 degrees4 – 8 sessions

Kerkoff et al, 1992Validated similar results in 92 hemianopic patients & 30 with

additional inattention/neglectFollowing 6 weeks of scanning training (30 sessions)Hemianope group: Mean search field increased from 15

degrees to 35 degreesAdditional Inattention/Neglect group; required 25% more

training over 2-3 months to achieve similar result

Page 65: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Visual Field Search training

• Goals: Increase awareness, establish compensatory scanning pattern into the deficit field which become automatic and accurate

Technique: Start with a small number of targets in the affected field and increase the number as proficiency improves• Continual verbal reinforcement to scan into the

affected field is required• Field enhancing prisms may be used (OD)

Page 66: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Types of visual search strategies with Hemianopia

Page 67: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Staircase Strategy (general compensation strategy without training)

Page 68: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Overshoot strategy:place remaining visual into blind field further than target expected (R visual

field loss)

X

Page 69: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Hemianopia and Reading Success Dr. Poppelreuter, German Neurologist Brain injured Vets -- WWI (1917)

Page 70: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Hemianopia and Reading Success Dr. Poppelreuter, 1917 (early in century) Interested in studying reading deficits in R & L

hemianopic WW1 veteransLeft visual field loss handicaps return eye movement

to find beginning of a new lineRight visual field loss handicaps eye movement to

next word/letter in sentence Right hemianopia more challenging since we read

left to right (trained to overshoot each word to successfully read)

Page 71: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Field Cut and Inattention/ Neglect

neuropolitics.org/hemineglect.gif

www.yvonnefoong.com/.../homonymoushemianopia.jpg

Page 72: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

VISUAL INATTENTION / Neglect: Figure Copying – What pieces of info is missed?

Describe room in balanced format?

Page 73: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Photosensitivity Definition: Intolerance of light

History: Patients complain they can’t transition quickly

I.e..: glare on floor, lights while driving, tearing, frequent blinking, squinting, headaches, irritability with visual activities

Types: photophobia vs. photosensitivity Photosensitivity exists in the absence of true pain, distinct from the

photophobia seen in patients with inflammatory ocular disease

Page 74: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Glare at night – trial 54% yellow tint and 40% Plum tint to reduce “halo”

Page 75: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Night Driving Glare

Page 76: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Other types of materials and equipment used

Page 77: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Parquetry Block tasks train systematic visual search and building concept

Page 78: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

HTS Visual Closure Therapy

Page 79: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Zoom text

Speech, Colors, Size, Internet Reverse screen polarity for light sensitivity and

increased font Regular laptops, computers, iPads have screen light

reduction, font adjustment, etc

Page 80: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

My Reader Patients who can read the text

but need higher level of text manipulation

Breaks up text to word-by-word, letter-by-letter, line-by-line, and ticker tape scrolling for problems with saccades or visual field cuts

CON: Not adaptable to the internet and not as portable, no speech

Page 81: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

KNFB Reader (Kurzweil and National Federation for the Blind)

Speech and limited text manipulation such as line-by-line

Portable but small screen

A.L. Could not process print due to disorders of accommodation and seccades. She spent so much effort trying to read that she could not process the information.

Page 82: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

CASE STUDIES

Page 83: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Acute TBI Case Study mod to severe TBI (IED blast, 1 month post trauma)

Sgt. Frank 26 year old Army Sergeant IED blast related injury

November 2004 with right hemisphere injury

General constricted visual fields

Needs assistance with food, dressing, etc.

Relearning to walk Memory deficit Speech Problems Left visual inattention Partial paralysis left side Checking the daily schedule

(note yellow reminder sheet of therapy sessions taped to left arm rest)

Page 84: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

A to Z Visual Scanning GameReinforcing Speech Therapy

Paul cueing to Pt. left area of neglectPt. points to and names target letter

Pt. hesitates while searching Target identified and named

Page 85: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Training Visual Tracking(head and eye movement)

Cueing centering Training can be monocular

Or binocular

Page 86: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Tracking in a Dynamic Setting

scan and identify targets (post-it notes)Pt. scanning, finding, pointing and identifying targets

Page 87: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Transfer to O&M

Pt. checking for cross traffic Pt. practicing scanning and obstacle identification

Page 88: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Physical Therapy and Vision Therapy co-tx

Paul cueing to correct

Pt. centering body and gaze

Pt. practicing centering and gait

Page 89: AER      CONFERENCE    2012 Visual  Anomalies from Brain Injury and Rehabilitation Strategies

Awareness of Patient endurance

Fatigue is common Multiple short (10 to 20

minute) lessons per day

Frequent rest breaks Time for “fun” activities