Download According to Brain Injury Assoc of America

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 studies
 Orientation & 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
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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
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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 Prognosis
Index
Mild
Moderate
Severe
GCS
13-15
9-12
<8
LOC
<30 min
<6 hours
>6 hours
Duration of 0-24 hours 1-7 days
PTA
Permanent Likely none Likely
neurologic
some but
& neuroare often
psychologi
quite
cal sequela
functional
>7 days
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.
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Moderate TBI

Severe TBI
10% - 30%
5% - 25%
 According to Brain Injury Assoc of America
Traumatic Brain Injury in America
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Not “just” a VA problem
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Polytrauma highlighted because of high
incidence of occurrence in Iraq / Afghanistan
(OEF/OIF)
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Relevance to community services
(Brain injury Association of America)
 1.4 – 1.7 million Americans sustain TBI Annually
○ One every 21 seconds
 700,000 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)
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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)
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-According to Brain Injury Assoc of America
Multiple TBI Risk Factors
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After 1 TBI, the risk for a 2nd is 3x greater
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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
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Polytrauma

Polytrauma is currently defined as
multiple injuries of which one (or a
combination) is life threatening.

Co-Morbidities associated with TBI
 Vision, 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
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Bullet Wound:
Entering Left Frontal-Temporal area,
Passing through parietal, midline into Right Occipital
area
Possibly 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 trauma
Occipital: 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, Florida
 Minneapolis, MN
 Palo Alto, CA
 Richmond, Va
 San Antonio, Tx
Richmond VAMC Population
(Mechanism of Injury)
since 2007
70
60
50
40
Blast/
Explosion
Vehicle
30
Bullet
20
Other
10
0
Richmond TBI rehab Population (Injury
Location)
*since Sept. 2007
90
80
70
60
50
40
30
20
10
0
Iraq
Afghanistan
Stateside
Other
Some Emerging Characteristics of
Polytrauma Patients
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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
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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 Functions
Left Brain Functions
uses logic
detail oriented
facts rule
words and language
present and past
math and science
can comprehend
knowing
acknowledges
order/pattern perception
knows object name
reality based
forms strategies
practical
safe
Right Brain Functions
uses feeling
"big picture" oriented
imagination rules
symbols and images
present and future
philosophy & religion
can "get it" (i.e. meaning)
believes
music
Facial recognition
spatial perception
knows object function
fantasy based
presents possibilities
risk taking
Visual Anomalies of Brain Injury
Binocular dysfunction Visual Field Loss often seen:
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Convergence
Accommodation
Saccadic/Pursuit
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 Ocular motor
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 Fixation
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Quadranopia
Hemianopia
macular sparing?
General Peripheral loss
Methods to create success and
independence through rehabilitation
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1. “Fix / Improve Vision” – vision therapy or surgery
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2. Use devices/lenses to improve vision (Magnifiers,
Telescopes, Rx, Readers, Prisms, white cane)
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3. Compensatory Strategies (eccentric fixation,
scanning to blind visual field, place reading stand in
better visual field)
Role of Vision Specialist
Consultative 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
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Role of Vision Specialist
Interventional 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 preestablished 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)
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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
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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
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Intervention Strategies
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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
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Screening and Assessment Process
Physician’s
Referral
Screening by
Vision
Specialist
Follow-up
by
Vision
Program
Referral to
Eye
Specialist
Vision
Program
F/U
SLP/OT/PT
Intervention
Glossary
 Accommodation
 Version
 Saccade
 Pursuit
 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
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Brahm et al., 2009 (all levels of TBI in Palo Alto VA hospital)
 39.6% of accommodative insufficiency
 42.6% of convergence insufficiency
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Goodrich et al, 2007 (all levels of TBI in Palo Alto VA hospital)
 21.7% had accommodative dysfunction
 30.4% had convergence insufficiency
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Ciuffreda et al., 2007 (Civilian, TBI rehabilitation)
 41 % had accommodative dysfunction
 42.5% had convergence insufficiency
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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
 Convergence Insufficiency
 Saccadic Dysfunction
 Dry Eye
 Accommodative issues
 Tropia (Eye Turn)
 Visual Field defects
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34%
31%
24%
23%
18%
13%
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
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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
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Reading with +/- power flippers
can be performed monoc. / binoc.
Hart Chart Activities (Saccades
and Accommodation therapy)
Version / Eye movement
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Definition: smooth eye movements in the same direction

Saccade - efficient eye movement from one fixation point to another
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Pursuit - two eyes ability to follow a target
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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 Saccades
Developmental Eye Movement (DEM)
Test A + B = C (time measured)
Saccadic Reading Exercises
Wayne Saccadic Fixator
Rehab strategies for Saccades
HTS (Home Therapy System)
Rehab strategies for Ocular
motor issues (Versions)
Vergence Eye Movement
Definition: 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
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Brahm et al., 2009 & Dougherty et al., 2010
 Visual 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
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Visual Search & Scanning with Visual
Field Loss
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Chedru et al., 1973
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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, 1988
 Trained 30 hemianopes (w/out inattention/neglect)
 Practice large saccades into blind field
 Visual search field increased 10-30 degrees
 4 – 8 sessions

Kerkoff et al, 1992
 Validated similar results in 92 hemianopic patients & 30 with
additional inattention/neglect
 Following 6 weeks of scanning training (30 sessions)
 Hemianope group: Mean search field increased from 15
degrees to 35 degrees
 Additional 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
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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 veterans

 Left visual field loss handicaps return eye movement
to find beginning of a new line
 Right 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
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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
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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
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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)
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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)
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Sgt. Frank
 26 year old Army Sergeant
 IED blast related injury
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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 Game
Reinforcing Speech Therapy
Paul cueing to Pt. left area of neglect
Pt. points to and names target letter
Pt. hesitates while searching
Target identified and named
Training Visual Tracking
(head and eye movement)
Training can be monocular
Cueing centering
Or binocular
Tracking in a Dynamic Setting
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
