Converging Views: Impact, Assessment & Management of
Acquired Brain Injuries
Sherry Rock OT Reg. (Ont)
Tammy Labreche OD, BSc
>400,000 Canadians living with disability as a result of stroke
Statistics Canada.Causes of Death, Canada, 2011.CANSIM data.Released January 28, 2014.
• ~ 800,000 individuals experience a stroke each year
• Leading cause of disability
Possible Visual Consequences of ABI
• 26% of those with ABI reported trouble with their vision most of the time…
The OBIA Impact Report 2012https://www.ontario.ca/img/[email protected]
Following a cerebrovascular accidents…
• Typical visual symptoms may include:
– Blur (sometimes intermittent)
– Double vision
– Difficulty tracking
– Trouble focusing
– Glare sensitivity and photophobia
– Loss of peripheral vision
• May also report:
– Eye strain/fatigue
– Difficulties with balance and posture
Kapoor N, Ciuffreda KJ. Vision Disturbances Following Traumatic Brain Injury. Current Treatment Options in Neurology. 2002:4: 271-280
Loss of Visual Function
• Decreased acuity
– NB importance of good refraction!
• Decreased contrast sensitivity
Cockerham GC et al. Eye and visual function in traumatic brain injury. JRRD. 2009:46(6): 811-818
Oculomotor control and accommodation
• Accommodative dysfunction
• Vergence issues/misalignment
• Version abnormalities
Visual Field Defects• Homonymous VF defects
http://www.perkinselearning.org/videos/webcast/visual-fields
Jones SA, Shinton RA. Improving outcome in stroke patients with visual problems. Age and Ageing. 2006;35:560-5
Visual Sequelae of Stroke
• Alignment/movement impairment – 68%
• Visual field impairment – 49%
• Low Vision – 26.5%
• Perceptual impairment – 20.5%
Rowe et al. A prospective profile of visual field loss following stroke: prevalence, type, rehabilitation, outcome. Biomed Research International. 2013: http://dx.doi.org/10.1155/2013/719096
Visual Versus Perceptual?
http://ih2.redbubble.net/image.14161792.3742/flat,550x550,075,f.jpg
Attentional/ Perceptual Changes
• Neglect
• Extinction
• Visual Midline Shift Syndrome
Neglect
• aka Unilateral Spatial Inattention
• Unawareness of one side of visual space
– Personal
– Peripersonal
– Extrapersonal
Suchoff IB, Ciuffreda KJ. A primer for the optometric management of unilateral spatial inattention. Optometry. 2004:75(5): 305-318.
Extinction
• Different from neglect??
• Selective impairment in awareness/response to a stimulus when presented simultaneously on both sides
http://ichef.bbci.co.uk/naturelibrary/images/ic/credit/640x395/c/cr/cretaceous-tertiary_extinction_event/cretaceous-tertiary_extinction_event_1.jpg
Vossel S et al. Visual Extinction in relation to visuospatial neglect after right-hemispheric stroke: quantitative assessment and statistical lesion-symptom mapping. J Neurol Neurosurg Psychiatry. 2011:82: 862-868.
Visual Midline Shift Syndrome (VMSS)
• aka Abnormal Egocentric Localization (AEL)
• Deviated perception of visual midline
– Poor eye/hand coordination
– Postural changes
– Diminished ability to navigate environment
Houston K E. Measuring visual midline shift syndrome & disorders of spatial localization: A literature review & report of a new clinical protocol. J Behav Optom. 2010:21(4): 87-93.
Functional Limitations of Visual Inattention/Visual Field Deficits
• Activities of Daily Living
• Instrumental Activities of Daily Living
– Home
– Community
• Leisure Interests
• Sand et al., 2015; Wolter et al., 2006; Warren, 2008;
• Warren, 2009)
http://www.bing.com/images/search?view=detailV2&ccid=PlG5w9KR&id=8C745074687AC273B0B92BA721A256739BD566C2&q=winnie+the+pooh+cooking+pictures&simid=608014379479272372&selectedIndex=0&ajaxhist=0
https://i.ytimg.com/vi/WRiP0XMEbyE/maxresdefault.jpg http://images2.fanpop.com/image/polls/5
06000/506986_1280770032921_full.jpg?v=1280770736
https://s-media-cache-ak0.pinimg.com/originals/a6/75/c8/a675c8dfb2d9726293bd4b067fa226d0.jpg
Assessment Tools
http://www.toolscartoon.com/multimedia/images/GROUP.GIF
Refraction
• May need to consider
trial frame refraction
Contrast Sensitivity
http://www.psych.nyu.edu/pelli/pellirobson/pelli-robson.gif
http://www.marsperceptrix.com/sites/marsperceptrix.com/files/styles/uc_product_full/public/MLCST%20black%20and%20white%20402%20x%20224_0.png?itok=8L9P8z2W
Oculomotor control/accomodation
• Proper prescription
• Vergences
• Accommodation
Visual Fields
http://www.customeyesvisioncare.com/user-files/visual_field.jpg
https://s-media-cache-ak0.pinimg.com/236x/1b/83/8c/1b838cc30369848251c5ccd76562452f.jpg
Neglect
https://www.google.ca/search?site=&tbm=isch&source=hp&biw=1253&bih=875&q=visual+perception&oq=visual+perception&gs_l=img.3..0l10.5614.9027.0.10510.17.8.0.9.9.0.77.523.8.8.0....0...1ac.1.64.img..0.17.556.oA9hkNDyf48#tbm=isch&q=line+bisection+test&imgrc=zAFVd7J7Qx9pEM%3A
https://classconnection.s3.amazonaws.com/200/flashcards/817200/jpg/space_processingppt-81338083594790.jpg
Line Bisection Copying Tasks
Extinction
https://www.clicktocurecancer.info/optic-nerve/images/2129_16_31-eye-schematic-confrontation-test.jpg
VMSS
www.padulainstitute.com
Occupational Therapy Assessment
• Detailed Subjective Assessment (client & caregiver)
• Brief visual screen/ Encourage client to get formalized eye assessment
http://images.clipartpanda.com/interview-clipart-Interview.png
Assessment Continued
• Generalized observation of client’s posture/movements
• Collaborate with other team members
• Functional Assessment
What to Watch For...
• Bumping into items• Missing items• Head position• Posture when sitting
(rotated/PPT/weight dispersion)• Posture when standing (weight
dispersion/rotation/pushing with hands)
• Hesitancy when walking• Keeping close to the wall• Hesitancy to come forward during a
transfer or when scooting on bed• Anxiousness when
walking/standing/transferring• (Nijboer, T. et al., 2014; Berryman et al., 2010; Warren, 2008;
Warren, 1998)
Bell’s Test
Created by Gauthier, Dehaut, and Joanette in 1989; http://www.strokengine.ca
Example of an Unorganized Search Pattern
Synopsis Management Optionshttp://www.algaecal.com/wp-content/uploads/options-treatment-guidelines-of-osteoporosis.jpg
Treatment: “Look” at the Whole Picture (Berryman et al. 2010’; Bierman et al., 2016; Hazzard, 2011)
Person
Environment
Task
Facilitation
The Task
• Make it motivating
• Make it functional if possible
• Consider the client’s impairments/skill level
• Ensure ``the just right challenge``
• (Warren, 1998; Warren, 2008)http://www.spirit-animals.com/wp-content/uploads/2013/10/parot-3.jpg
http://classroomclipart.com/images/gallery/Clipart/Food/Grocery_Clipart/TN_lady-shopping-at-grocery-store-clipart.jpg
The Task
Incorporation of kinesthetic/ motor input (Berryman et al. ,2010; Luukkainen-Markkula et al., 2009; Profitis, et al., 2013;
Spaccavento et al., 2016; Warren, 2008)
The Environment
– Contrast
– Lighting
– Uncluttered environment
– Consistency
– Amount of distractions
– Size of environment
– Stationary/dynamic(Warren, 1998; Warren, 2008)
Facilitation
• Anchors/visual cues
• Ask question versus tell client
• Encourage reflection/problem solving from the client
• (Vossel et al., 2013)
https://i0.wp.com/cerasis.com/wp-content/uploads/2013/09/problem-solving-steps.jpg
Facilitation Con’t
Lighthouse adaptation (Niemeier, 1998; Pereira Ferreira, 2011)
http://d3seu6qyu1a8jw.cloudfront.net/sites/default/files/images/iStock_000013186131Medium.jpg
https://i.ytimg.com/vi/2e8vtFDZNoA/maxresdefault.jpg
• Proper Spectacle Prescription!
• Filters
• Vision Therapy
• Yoked prisms
• Magnification?
• Field Enhancement
– Orientation and Mobility Training
Field Enhancement
http://archopht.jamanetwork.com/data/journals/ophth/6878/s_ecs70078f4.png
Image courtesy of Eli Peli
Facilitation: Collaboration is Key
• Ongoing client and caregiver education
• Managing expectations
Team Effort
• Collaborate with team members
• (Norup et al., 2016)
https://www.ctvnews.ca/polopoly_fs/1.2610347.1444868279!/httpImage/image.jpg_gen/derivatives/landscape_620/image.jpg
Grading The Task and Environment
• Provide the “just right challenge”
– More compensation → Less compensation
– Less cluttered → More cluttered scanning tasks
– Small field →Larger field to scan
– Stationary →Dynamic tasks
– Less distractions → More distractions(Berryman et al. , 2010; Warren, 1998; Warren, 2008)
Other Occupational Therapy Treatment Ideas
Scanning Boards(Warren, 1998; Warren, 2008)
Scanning Wall(Warren, 1998; Warren, 2008)
Light Show(Warren, 1998; Warren, 2008)
Scanning Hallway(Berryman et al. , 2010; Warren, 1998; Warren, 2008)
Consider the Client`s Interests
• Flyers• Money• Magazines• Menus• Schedules• Bookshelves• Items from or in kitchen• Items from or in bathroom• Items from or in stores• Card games• Board games• Puzzles• Computer tasks• Lego/constructional tasks• Word Searches• Books (cross out the “the’s”)• (Berryman et al. ,2010; Luukkainen-Markkula et al., 2009; Profitis, et al.,
2013; Spaccavento et al., 2016; Pereira Ferreira, 2011; Warren, 2008)
http://smartcanucks.ca/wp-content/uploads/2013/03/FlyerSneakPeeks-500x285.png
http://www.milefoot.com/math/discrete/counting/images/cards.png
http://www.clipartkid.com/images/88/what-is-your-guilty-pleasure-KKxO4R-clipart.JPG
Occupational Therapy Treatment
• Lots of homework
– Scanning sheets
– Functional tasks• (Berryman et al., 2010; Proto et al., 2009; Vossel et al., 2013;
Warren, 2008; Warren, 1998)
Scanning Sheets
Bringing It Together: Case Study
• 67 year old female• CVA in July, 2016• Inpatient rehab for approximately 3 months; transferred to
outpatients• Assessed in Outpatient Clinic in October, 2016 for OT and
PT• Goals:
– 1)Achieve functional use of left upper extremity– 2) Increase independence in ADLs and IADLs; – 3) Increase independence in ambulation;– 4)Return to driving; – 5)Return to volunteer work
Functional Status
• Assistance for ADLs
• Dependent for most IADLs
• Reduced community involvement
Assessment Findings
• Cognitive and Perceptual Challenges: – Reduced attention
– Missed items on the left/right when walking
– Unorganized search pattern demonstrated on paper tasks
– Found items on right before left on paper tasks
• Physical Challenges:
– Left hemiparesis
– Head tilted and turned to left
– Left upper trunk rotated back
– +++cuing to shift weight to left in sitting and standing
• Vision assessment findings:
Best corrected visual acuity 6/6 OD, OS and OU
Binocular vision within normal limits
Contrast sensitivity mildly reduced
• Visual challenges:
– ?resolving left hemianopsia
– Unable to assess extinction
– Right mid line shift???
Treatment
• Collaborated with and educated client, caregiver and multidisciplinary team
• Encouraged left to right scanning for all functional tasks
• Worked with left upper extremity in active support for all tasks
• Encouraged reflection• Homework
• Prisms in therapy only
http://xtremeopticsinc.com/prism-lenses/low-vision-eyeglasses/files/fullsizeimage_748.jpg
Outcomes
• Participating more in ADLs and IADLs
• Getting out with friends with supervision
• Walking with walker but still forgets about left hand
• With prisms: improved midline alignment
• Improved scanning pattern but continues to miss items
• Still requires cuing to scan left to right
Bell’s Test: Before Prism Adaptation Theory
Bell’s Test: After Prism Adaptation Theory
Take Home Message:
• Vision cannot be overlooked- it impacts everything
• No concrete recipe regarding assessment/treatment
• Team Approach• (Norup et al, 2016)
http://www.keepcalmstudio.com/_gallery/300/1o4OrS9.png
ReferencesBarker-Collo, S et al. Attention deficits after incident stroke in the acute period: Frequency across types of attention adn relationships to patient characteristics and functional outcomes. Topics in Stroke Rehabilitation. 2010. 17(6). 463-476.Berryman A et al. Practical clinical treatment strategies for evaluation and treatment of visual field loss and visual inattention. NeuroRehabilitation. 2010: 27: 261-268.Bierman, J. et al. NeuroDevelopmental Treatment: A Guide to NDT Clinical Practice. New York: Thieme. 2016.Ciuffreda KJ et al. Occurrence of oculomotor dysfunction in acquired brain injury: A retrospective analysis. Optometry. 2007:78(4): 155-161.Cockerham GC et al. Eye and visual function I traumatic brain injury. JRRD. 2009:46(6): 811-818Colarusso, R. P. et al. Motor-Free Visual Perception Test (3rd edition). Novato, CA: Academic Therapy Publications. 2003.Hazzard, C. Advanced Handling and Problem Solving course notes. 2011. Houston K. Vision care for the brain-injured patient. Review of Optometry. 15 Mar. 2013: 73+. Academic OneFile. Web. 27 Mar 2015.Houston K E. Measuring visual midline shift syndrome & disorders of spatial localization: A literature review & report of a new clinical protocol. J Behav Optom. 2010:21(4): 87-93.Jehkonen, M et al. Driving ability in stroke patients with residual visual inattention: A case study. Neurocase. 2012: 18(2). 160-166. Jones SA, Shinton RA. Improving outcome in stroke patients with visual problems. Age and Ageing. 2006;35:560-5Kapoor N, Ciuffreda KJ. Vision Disturbances Following Traumatic Brain Injury. Current Treatment Options in Neurology. 2002:4: 271-280Lannoo E et al. Epidemiology of acquired brain injury (ABI) in adults: prevalence of long-term disabilities and the resulting needs for ongoing care in the region of Flanders, Belgium. Brain Injury. 2004: 18(2): 203-211.Luukkainen-Markkula, R. et al. Rehabilitation of hemispatial neglect: A randomized study using either arm activation or visual scanning training. Restrorative Neurology adnNeuroscience. 2009: 27:663-672.Massucci ME. Prism adaptation in the rehabilitation of patients with unilateral spatial inattention. J Behav Optom. 2009: 20: 101-105.Niemeier, J. The lighthouse strategy: use of visual imagery technique to treat visual inattention in stroke patients. 1998. Brain Injury. 12(5). 399-406.Nijboer, T. et al. Prismadaptation improves postural imbalance in neglect patients. Cognitive neuroscience and neuropsychology. 00(00): 2014: DOI:10.1097/WNR.0000000000000088Norup, A. et al. An interdisciplinary visual team in an acute adn sub-acute stroke unit: Providing assessment and early rehabilitation. NeuroRehabilitation. 2016: 39. 451-461.Pereira Ferreira, H. et al. Is visual scanning better than mental practice in hemispatial neglect: Results from a pilot study. Topics in Stroke Rehabilitation. 2011:18(2):155-161.Priftis, K. Et al. Visual scanning training, limb activation treatment, adn prism adaptation for rehabilitating left neglect: who is the winner? Human Neuroscience. 2013: http://doi: 10.3389/fnhum.2013.00360 Proto, D et al. Assessment and rehabilitation of acquired visuospatial and proprioceptive deficits associated with visuospatial neglect. NeuroRehabilitation.2009: 24:145-157.Rowe et al. A prospective profile of visual field loss following stroke: prevalence, type, rehabilitation, outcome. Biomed Research International. 2013: http://dx.doi.org/10.1155/2013/719096Sand, K. M et al. Vision problems in ischaemic stoke patients: effects on life quality and disability. European Journal of Neurology. 2015. 23(1). 1-7.Spaccavento, S. et al. Efficacy of visual-scanning trainig adn prism adaptation for neglect rehabilitation. Applied Neuropschology: Adult. 2016: 23(5). 313-321.
Suchoff IB, Ciuffreda KJ. A primer for the optometric management of unilateral spatial inattention. Optometry. 2004:75(5): 305-318.
Suchoff IB et al. The frequency of occurrence, types, and characteristics of visual field defects in acquired brain injury: a retrospective analysis. Optometry. 2008: 79(5): 259-265.
The OBIA Impact Report 2012. https://www.ontario.ca/img/[email protected]. Retrieved May 2016.
Vossel S et al. Visual Extinction in relation to visuospatial neglect after right-hemispheric stroke: quantitative assessment and statistical lesion-symptom mapping. J Neurol Neurosurg Psychiatry. 2011:82: 862-868.
Vossel, S. et al. Anosognosia, neglect, extinction and lesion site predict impairment of dail living after right-hemispheric stroke. Cortex. 49. 1782-1789. doi:10.1016éj.cortex.2012.12.011
Warren, M. biVABA: Brain Injury visual assessment battery for adults. 1998: visABILITIES Rehab Services Inc.
Warren. M. Evaluation adn Treatment of Visual Perceptual Dysfunction in Adult Brain Injury (Part 1). Course notes: 2008.
Warren, M .et al. Pilot study on activities of daily living limitations in adults with hemianopsia. The American Journal of Occupational Therapy. 2009. 63(5). 626-633.
Warren, M .et al. Search performance of healthy adults on cancellation tests. The American Journal of Occupational Therapy. 2008. 62(5). 588-594.
Wolter, M et al. Visual deficit following stroke: Maximizing participation in rehabilitation. Topics in Stroke Rehabilitation. 2006. 13(3). 12-21.