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: Paul.koons@va.gov

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

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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

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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