aer conference 2012 visual anomalies from brain injury and rehabilitation strategies
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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 PresentationTRANSCRIPT
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]
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)
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
Disclaimer statement This presenter has no financial interest
in any of the makes, models of rehab equipment, devices, sunwear or assessment tools
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)
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
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
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
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
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
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
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
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”
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
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
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
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
Improvised Explosive Devices (IEDs)
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
Polytrauma Veterans Affairs
5 Main Polytrauma VA Hospitals in U.S.A.
Tampa, FloridaMinneapolis, MNPalo Alto, CARichmond, VaSan Antonio, Tx
Richmond VAMC Population (Mechanism of Injury)
since 2007
0
10
20
30
40
50
60
70
Blast/ExplosionVehicle
Bullet
Other
Richmond TBI rehab Population (Injury Location)*since Sept. 2007
0102030405060708090
IraqAfghanistanStatesideOther
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
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)
Site of Lesion
Visual Pathway - numbers indicate how lesion affect visual field(s)Red/Blue = image seen Gray = blind area
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
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
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)
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
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)
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
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
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
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
Screening and Assessment Process
Vision Program
F/U
SLP/OT/PT Intervention
Glossary Accommodation Version
SaccadePursuit
Convergence Divergence Visual Fields Photosensitivity
changizi.wordpress.com
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
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
Accommodation Definition: ability to focus near and distant targets Measure Accommodation monocularly (diopter) Our eyes ‘bending’ power
Rehab strategies for Accommodation insufficiency
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
Reading with +/- power flipperscan be performed monoc. / binoc.
Hart Chart Activities (Saccades and Accommodation therapy)
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)
Large and Small Saccades
Large Visual Saccades
Reading with small visual saccades
Rehab strategies for SaccadesDevelopmental Eye Movement (DEM)Test A + B = C (time measured)
Saccadic Reading Exercises
Wayne Saccadic Fixator
Rehab strategies for SaccadesHTS (Home Therapy System)
Rehab strategies for Ocular motor issues (Versions)
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
Rehab strategies for Convergence/Divergence
Brock string for Convergence & Divergence - may include fusional prisms
Vectogram activity for Convergence / Divergence
Neurological Field Loss Strategies
Reading with R hemianopia
Reading with Left Hemianopia
Brahm et al., 2009 & Dougherty et al., 2010Visual field loss testing is recommended for
patients with a history of TBI
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
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
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
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)
Types of visual search strategies with Hemianopia
Staircase Strategy (general compensation strategy without training)
Overshoot strategy:place remaining visual into blind field further than target expected (R visual
field loss)
X
Hemianopia and Reading Success Dr. Poppelreuter, German Neurologist Brain injured Vets -- WWI (1917)
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)
Field Cut and Inattention/ Neglect
neuropolitics.org/hemineglect.gif
www.yvonnefoong.com/.../homonymoushemianopia.jpg
VISUAL INATTENTION / Neglect: Figure Copying – What pieces of info is missed?
Describe room in balanced format?
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
Glare at night – trial 54% yellow tint and 40% Plum tint to reduce “halo”
Night Driving Glare
Other types of materials and equipment used
Parquetry Block tasks train systematic visual search and building concept
HTS Visual Closure Therapy
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
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
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.
CASE STUDIES
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)
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
Training Visual Tracking(head and eye movement)
Cueing centering Training can be monocular
Or binocular
Tracking in a Dynamic Setting
scan and identify targets (post-it notes)Pt. scanning, finding, pointing and identifying targets
Transfer to O&M
Pt. checking for cross traffic Pt. practicing scanning and obstacle identification
Physical Therapy and Vision Therapy co-tx
Paul cueing to correct
Pt. centering body and gaze
Pt. practicing centering and gait
Awareness of Patient endurance
Fatigue is common Multiple short (10 to 20
minute) lessons per day
Frequent rest breaks Time for “fun” activities