ODs can play a role in rehab for mTBI

After a period of rest, optometrists can begin a rehabilitation program.

Issue: February 2018

ByJoseph Hallak, OD, PhD, FAAO

ByJeffrey Becker, OD

Mild traumatic brain injury is a serious concussive injury induced by biomechanical forces and not easily detectable by neuro-imaging. It results in various visual, perceptual, oculomotor and oculovestibular dysfunctions interfering with numerous activities of daily living.

Glare sensitivity, crowding, lack of concentration, balance issues and convergence insufficiency are examples of the constellation of visual and perceptual symptoms of the afflicted patient. After a period of rest and recuperation (4 to 6 weeks) and barring any subsequent injury, an optometric program of rehabilitation can be started.

Extensive case history, testing

The process should begin with an extensive case history. The examiner needs to explore how the vision and vestibular symptoms affect the activities of daily living (ADL), such as driving, working, reading, memory and household activities.

Do they affect the ability to go into busy places? Does the patient have any specific glare issues, especially with fluorescent lighting? Finally, and most importantly, was the onset of symptoms prior to or after mild traumatic brain injury (mTBI) or TBI?

Objective testing should include electrodiagnostics such as electronystagmography (fixation, eye movement), Vestibular Auto Rotation Test, computerized optokinetic stimulation testing and balance testing. These objective tests can often help the patient understand their disorder and, thereby, concentrate on realistic goals.

Subjective testing involves the usual complete binocular examination, but it should be done in free space using handheld instruments as much as possible. Myopia and eso posture measured behind the phoropter are not true to form; they measure differently in free space. Rely more on cover testing, Maddox rod phorias, prism bar ductions, accommodative flipper, depth perception and vestibular-ocular reflex eye movements.

Goals

Vision rehabilitation of the mTBI and TBI patient can be significantly different than vision therapy for convergence insufficiency or a learning-related vision problem. The visual/vestibular system recovers much more slowly than with routine convergence insufficiency due to a delayed integration process.

ADL goals should be both short-term and long-term and attainable, taking into account significant emotional, behavioral, as well vestibular deficits that may influence the rehabilitation process.

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Any type of rehabilitation will require the patient to understand their deficits. Defining, understanding and setting realistic goals is a great motivator, and all parties involved in the patient’s life should understand them. A good doctor-patient relationship is essential.

Patients need to understand that treatment is necessary for proper recovery and good outcomes so that they can return to a good quality of life. This is why objective and subjective testing is important and should be explained.

The patient’s ability and cognitive skills are as important as visual acuity and acceptable visual field for safe driving. Deficits in multitasking, crowding phenomenon, driving commotions, attention and concentration all play a role.

Working with other disciplines

It is important to include other professionals who can assist in the patient’s total recovery within a comprehensive and coordinated process. These professionals should include occupational physical therapists who understand balance and vestibular therapy, physiatrists who handle and manage concussions and head trauma, and neuropsychologists who can assist in the total emotional and behavioral aspects of the rehabilitation process.

In-office rehabilitation

Vision rehabilitation therapy can be provided in many settings, the most common of which is the optometrist’s office. However, a trained occupational therapist (OT) can add new techniques to enhance the total rehabilitation process within the patient’s everyday environment.

With the Americans With Disabilities Act, our offices need to be handicap accessible and adaptable to patients’ needs. For example, the Sanet Vision Integrator (SVI) is on a mobile stand that can be easily adjusted for height and target size. A movable exam chair offers convenience and saves “chair” time.

The SVI computer program assesses and develops eye-hand coordination from a proaction, reaction and hand speed point of view; it includes audio feedback and incorporates balance. A graphing feature helps the patient and therapist track progress.

Vision rehabilitation therapy should include multiple treatment programs in free space as much as possible using handheld devices as well as computerized programs. The programs should include monocular, bi-ocular (one eye at a time) and binocular eye movements (for convergence) at the appropriate distance.

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The computerized Home Vision Therapy System (HTS) is convenient. The Marsden ball can be used with and without a septum for both bi-ocular and binocular exercises. Static and dynamic Brock strings are used binocularly in free space and in various directions at home and office. The addition of a balance board, balance beam and mini trampoline in some cases, such as with the Marsden ball, helps with both the oculomotor/oculovestibular training to integrate eye-hand-perceptual skills. The SVI incorporates balance and the vestibular system.

Training exercises in free space, whether in a static or dynamic mode, training while balancing on a board and continuous regular home exercises can help the patient achieve integration, internalization and endurance.

Extreme caution must be exercised when yoked prisms (prisms in the same horizontal direction binocularly) are used. By shifting the perceived visual field, these prisms disturb the oculomotor perceptual system, thereby forcing a recalibration and readjustment, leading to, it is hoped, a process of internalization. It is a delicate phase of therapy.

Home therapy systems

Patients need to adhere to a maintenance program at home once discharged from office therapy. The incidence of regression can range from 10% to 15% when treatment is stopped.

Handheld items such as Brock strings and free space fusion cards work well. The HTS or Web Vision Therapy programs are comprehensive, computerized home systems that can be customized for maintenance and monitored remotely from the office, ensuring compliance.

It is important to keep in mind the three phases of neuro-optometric rehabilitation:

visual stabilization: postural/peripheral awareness, monocular skills;
binocular vision integration: oculomotor/accommodative, convergence, stereopsis, localization (static and dynamic); and
visual automaticity: multisensory integration.

Next month we will present the case of a man involved in a motor vehicle accident who suffered an mTBI/concussion and underwent a comprehensive outpatient vision/vestibular therapy program.

References:
Armstrong RA, et al. Optom Vis Sci. 2017;doi:10.1097/OPX.0000000000000911.
Becker JB. Efficacy of vision therapy on the neurologically impaired. Presented at: American Congress of Rehabilitation Medicine; San Francisco; November 1992.
Becker JB. Equipment and treatment. Presented at: AOTA annual conference; Philadelphia; 1992.
Becker JB. Vision therapy, rehabilitative outcomes, literature review, vision therapy techniques. Presented at: Ophthalmology and Optometry Symposium; Riyadh, Saudi Arabia, March 2013.
Brain Injury Research Institute. What is a concussion? www.protectthebrain.org. Accessed December 12, 2017.
Capó-Aponte JE, et al. Mil Med. 2012;177(7):804.
Capó-Aponte JE, et al. Optom Vis Sci. 2017;doi: 10.1097/OPX.0000000000000825.
Chang TT, et al. Brain Injury. 2007;doi:10.1080/02699050701591437.
Defense Centers of Excellence for Psychological Health & Traumatic Brain Injury: Traumatic Brain Injury. Washington DC, 2011. Available at http://www.dcoe.health.mil/Content/Navigation/Documents/About% 20TBI.pdf.
Eisenberg MA, et al. Pediatrics. 2014;doi: 10.1542/peds.2014-0158.
Friedman NJ, et al. The Eye Exam. Essentials of Ophthalmology. 2007.
Goodrich GL, et al. J Rehabil Res Dev. 2007;44:929–936.
Harmon KG, et al. Br J Sports Med. 2013;doi: 10.1136/bjsports-2012-091941.
Kapoor N, et al. Curr Treat Options Neurol. 2002;(4):271-280.
Logan K. Athletic Therapy Today. 2010;doi:org/10.1123/att.15.3.4.
McCrory P. J Clin Sport Med. 2001;11:144-149.
McCrory P, et al. Br J Sports Med. 2013;doi:10.1136/bjsports-2013-092313.
McCrory PR, et al. Neurology. 2001;57(12):2283-2289.
Omalu BI. Concussion and Traumatic Brain Injury through the Lifespan. UC Davis Public Forum, October 21, 2015.
Omalu BI. Prog Neurol Surg. 2014;doi:10.1159/000358761.
Poltavski, D. Optom Vis Sci. 2017;doi:10.1097/OPX.0000000000001094.
Porter JD. J Neuro-Ophthalmol. 1995;15(2):126-127.
Rakic P, et al. Constraints on neurogenesis in adult primate brain: An evolutionary advantage? In: Cuello AC, ed.
Restorative Neurology. Vol. 6, Neuronal Cell Death and Repair. Amsterdam: Elsevier; 1993:257-266.
Scheiman M. Understanding and Managing Vision Deficits: A Guide for Occupational Therapists. 2002. Thorofare, NJ: Slack.
Suter PS, Harvey LH. Vision Rehabilitation: Multidisciplinary Care of the Patient Following Brain Injury. Boca Raton, FL: CRC Press. In press.
Yuhas PT, et al. Optom Vis Sci. 2017;doi:10.1097/OPX.0000000000000934.

For more information:
Jeffrey Becker, OD, is director of vision rehabilitation at the Neurosensory Center of Eastern Pennsylvania and a consultant to many rehabilitation hospitals. He can be reached at jeffreyb20@aol.com.
Joseph Hallak, OD, PhD, FAAO, is in private practice in Syosset, N.Y. He can be reached at drjhallak@aol.com.

Disclosures: Becker and Hallak report no relevant financial disclosures.