Download Additional Concerns and Various Specialists to Consider

Vision Specialists
Institute
Mark Rosner, M.D.
Director of Research
Debby Feinberg, O.D.
Director of Clinical Instruction
Additional Concerns and Various Specialists to Consider
Often times a patient may have symptoms which cannot be relieved with a prismatic correction. In these
instances, you may be an important source of referral for your patients.
1) Anxiety
a) Anxiety is a common symptom associated with the visual system in many cases; however,
correcting the visual piece may not eliminate the symptom all together.
b) Sometimes, in the case of PTSD, the glasses will not help fully. Refer these patients for bio/neuro
feedback. Software systems, like Heart Math or Journey to the Wild Divine by Deepak Chopra and
Andrew Wile, can visually calm the nervous system down.
c) Sometimes it’s helpful for patients to be introduced to meditation specialists. You may be able to
find a meditation specialist in your area through the Transcendental Meditation website.
http://www.tm.org/?leadsource=CRM984&gclid=COeh357RybwCFY1FMgodlAgAiw
d) Anxiety specialists are trained to help patients in person or over the phone.
i) Ex: Wendy Koebel – therapist and life coach (trained social worker) will help people over the
phone. Contact her at (248) 321-1953 or http://wendykoebel.com/index.html
e) Yoga – patients can also use yoga as an avenue to calm their anxiety
2) Attorneys
a) Having an attorney on board is helpful when insurance companies are denying payment on your
behalf.
3) Case managers
a) Case managers can be invaluable advocates for your patients.
b) Insurance companies in the state of MI will pay for case manager fees.
c) They come to appointments, document care, and work with the PM&R Doctors.
4) Dependence on pharmaceutical medications
a) Often times when patients have seen 10-12 doctors before seeing you, they may be on multiple
medications that can worsen their dizzy and headache symptoms. You may need to be in touch with
their Psychiatrist/Neurologist/Internist regarding the impact the medications have on the visual and
vestibular systems.
b) It can be difficult to arrive at a final prism prescription when patients are on such medications. An
addiction medicine physician can help to carefully wean the patient off of their various medications.
c) The Road Back is a helpful website for patients who don’t have access to an addiction medicine
doctor. It can provide them a guideline to properly wean off the medicines. http://theroadback.org
d) Holistic psychologists can also help with weaning off of medications.
e) Doctors may also use a compounding pharmacy when helping patients wean off of pharmaceutical
medications. They are capable of producing the medication in liquid form, allowing for very small
changes (decreases) in medication doses, which makes weaning easier to do.
5) Difficulty w/driving
a) Once patients are helped with prismatic correction, they may be ready to begin driving again. There
are driver rehab programs available through local hospitals where patients can be retrained on how
to become confident drivers once again.
6) Endocrinology
a) When the brain is injured, many systems are affected including the hormonal system.
b) A new area of interest where patients with brain injury are being helped is the use of growth
hormone.
i) Dr. Nasir Haque of Waterford, MI, specializes in such work;
www.emdclinic.com (248) 738-0755
7) Eyes
a) Strabismus surgeon: Consult when patients require an amount of prism physically impossible to put
inside a pair of glasses.
b) Retinal specialists: Often times, after patients have retinal repair surgery, they may experience
diplopia. The retinal specialist will need your help in coordinating the patients’ eyes with prism.
c) Oculoplastic surgeon: After an air bag deploys in a patients face, they can have a prolapse of the
lacrimal gland. This may require oculoplastic surgical repair.
d) Ophthalmologists who specialize in dry eye can be very helpful as well.
8) Facial pain
a) Occasionally patients will have facial pain due to a fall or injury, where scar tissue has formed in the
cheek region. These patients can benefit from Craniosacral Therapists who work with their hands
inside the patient’s mouth, working to break apart the scar tissue and eliminate the pain.
i) You can look for a Craniosacral Therapist in your area through the Upledger Institute.
b) Patient’s with facial pain may require Plastic/reconstructive surgery of the face. Oral and
maxillofacial surgeons may also do this type of work.
c) Occasionally you will work with patients who have had multiple facial surgeries with plates inserted
into the face to reconstruct the orbit.
i) These plates may move, causing the patient to return to those surgeons for reassessment.
ii) The movement of the plates can greatly affect their eye alignment.
9) Identifying TBI patients
a) Neurologists
i) Functional MRIs can be very helpful in identifying a brain injury when a traditional MRI is not
able to.
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(1) There are occasions when insurance companies will deny that a brain injury has occurred.
The special imaging from a functional MRI will help confirm that a brain injury actually
occurred.
(2) Neurologist, Dr. Randall Benson, specializes in Functional MRIs.
http://neurologicstudies.com
b) Neuropsychologist
i) Often consulted by PM&R doctors to formally document that a traumatic brain injury has
occurred. They perform extensive cognitive testing to help identify areas of weakness in a
patient who may have sustained a traumatic brain injury. The PM&R will use these results to
help support the diagnosis of brain injury.
10) Lymphatic drainage
a) This technique is performed by Physical Therapists who work with gentle touch on the body; they
help those who have disrupted digestive functioning following head injury.
11) Musculoskeletal Pain – Neck & Shoulder
a) Acupuncturist
b) Craniosacral therapist – Craniosacral therapy is a unique form of manual manipulation which
focuses on healing the body with miniscule amounts of pressure. You can find therapists in your
area through the Upledger Institute which provides classes and training for the technique. Each
therapist may have a different level of training, which is also noted on the website.
http://www.upledger.com/aboutUs.asp
i) In order for the therapy session to be covered by insurance the patient will need a prescription
for manual therapy from their internist: “manual PT, 6-8 weeks, 2-3 times/week”.
ii) Sessions can be very expensive; therefore, it is very important to have them covered by
insurance.
c) Bowen Specialist
d) Korean Specific Technique
e) Healing touch
f) Chiropractors
o Nucca – specific chiropractic specialty focusing on the upper cervical part of spine (C1C2). They rarely do sever manipulation; they use thermal scans to view the spine, and
work with gentle light touch to align the spine in the cervical region.
o Neurochiropractic medicine – these specialists work with patients with brain injury.
Usually these brain injury patients will be working in combination with a PM&R
physician and neurochiropractor.
g) Neck surgery – sometimes neck pain does not go away despite appropriate treatments. These
patients require an MRI of neck and may have severe problems that require neck surgery.
12) Music therapy
a) Music therapists can help with brain healing for TBI patients.
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13) The Non-pharmaceutical approach
a) Functional medicine/complimentary medicine/holistic medicine all reflect on a new type of
integrative health care which often relies on non-pharmaceutical approaches to medical treatment.
b) This is most common in doctors of osteopathy (DO), but can be seen with traditional medical
doctors (MD) as well.
14) Pelvic pain
a) Some Physical Therapists specialize in helping align the pelvic floor.
b) Carla Morton, M.D. is a PM&R doctor that helps patients with specialized exercises to align their
bodies; (248) 569-9330
15) PM&R
a) PM&R Doctors have different sub-specialties. Some work on pain management or spine, while
others work exclusively to the brain injury population.
b) There are also pediatric PM&R Doctors who work exclusively with children with brain injury.
16) POTS
a) When sorting dizzy patients, in many cases the symptom can be resolved by prism glasses.
b) Sometimes the dizziness is related to a lack of blood flow to the brain. These patients may have
Postural Orthostatic Tachycardia Syndrome (POTS).
c) Refer to an EP Cardiologist.
d) The definite test for POTS is tilt-table test. But very often they can also be sorted by orthostatic
blood pressure/pulse test.
i) In a quiet, dimly lit room, take the patients BP and pulse while laying down for 5 minutes, sitting
for 2 minutes, and standing for 2 minutes. If the change in pulse from laying down to standing is
greater than 20 beats/min, the results are abnormal, and the patient should be checked by their
primary care doctor. If the patient has POTS, they must have at least a 30 beat/min increase. If
the systolic BP (top number)drops greater than 20 mm Hg, it is also abnormal, and the patient
should be checked by their primary care doctor.
ii) Refer any patient that might have POTS (pulse increase of at least a 30 beat/min) to an EP
Cardiologist.
17) Seizures
a) Sometimes patients continue to have poorly controlled seizures. Refer to a that specializes in
treating seizures.
b) Dr. Jason Schwalb, the Director of Movement Disorder and Behavioral Neurosurgery at Henry Ford
Hospital is comfortable evaluating complicated seizure patients. (248) 661-6417.
i) Dr. Schwalb has performed Vagal Nerve Stimulator (VNS) implant surgeries, which have helped
eliminate patients’ seizures.
ii) The VNS is similar to a pacemaker, for the brain. They are programmed to send a signal to the
brain every 5 minutes for 30 seconds to help regulate the nervous system.
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18) SSCD
a) Prism may not eliminate a patient’s dizziness for various reasons. When sorting a patient’s
dizziness, you will want to use the Superior Semicircular Canal Dehiscence (SSCD) questionnaire to
sort their specific symptoms as they relate to the inner ear.
b) A score of 10/16 or higher on the SSCD questionnaire is significant, and indicates the patient would
likely benefit from an SSCD evaluation.
c) Refer these patients to an Otologist. These doctors will perform a temporal bone CT scan, O-Vemps,
and other various tests to positively identify if the patient has true SSCD.
19) Stabilizing gait
a) After their injury, patients may need help with gait normalization though the use of orthotics and
physical therapy.
20) TMJ
a) When patients are in auto accidents or injuries, they can have painful TMJ symptoms. Once you
have corrected their eye misalignment and reduced symptoms, if they remain with jaw clicking or
other symptoms of jaw pain, refer the patient to a dentist who specialize in helping patients with
jaw alignment.
21) Transportation
a) Very often patients do not drive, and it is helpful to have the name of transportation companies.
i) This transportation is often billable to the insurance company.
22) Vocational Rehab
a) Often patients with mild-moderate brain injury are not able to perform the job they had prior to the
TBI. In such cases, it’s helpful to have different avenues for vocational training.
i) Rehab counselors work to help identify a new area of interest the patient can get involved in
post TBI.
ii) Vocational rehab proved to be very inspirational to one of our patients who took up
photography, and went on to publish his first book of photos; http://tbiphoto.com
iii) Sometimes just having a place to go where the patient’s feel helpful is very emotionally
uplifting. Cassell & Associates provides such an environment, and is covered by auto insurance
in the state of Michigan. http://www.cassellandassociates.com
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