Neurorehabilitation of Visual Impairments

Field Defects – Diplopia – Balance –Dizziness--Reading Problems

Stan Appelbaum, OD, FCOVDBryce Appelbaum, OD, FCOVD

Neuro Optometry & Vision TherapyBethesda & Annapolis, Maryland

301-897-8484www.VisionHelp.com

www.AppelbaumVision.com

Visionary Ophthalmology

Rockville, MarylandMarch 8, 2015

Concussions, TBI, Reading, Balance, Car-Sickness, Attention, & Visual Fatigue Problems

Vision Therapy 101 for The Primary Care Practitioner

Sept. 26, 2011

OT ADVANCE

cover story

”At First Sight”

Husband and wife team,

Stan Appelbaum, OD, FCOVD

& Barbara Bassin, OTR/L, BCP

practice with their son,

Bryce Appelbaum, OD, FCOVD

Sept/Oct 2014 Bethesda Magazine

Seeing Success: Vision therapy is helping patients get their eyes back on track

By Stacey Colino

Understanding and Managing Visual & Vestibular Deficits

This Seminar Will…

• Secure your understanding of the essential synchronicity of visual and vestibular function

• It will dispell that myth that 20/20 is perfect vision

• It will give you practical testing and treatment methods

Does 20/20 visual acuity insure you can see a 3-ring circus?

What do you see in this picture?

Now do you see it?Visual recognition is more than detail detection

The visual brain is more than the eyes and occipital lobe

Vision…More than acuity

• Vision is a process

• Good vision requires the effective input of visual information

• Good vision requires the effective processing and integration of visual information

• Good vision is this culmination through which we make use of visual information

BAOD Syndrome…The vision triad that causes impairment

• Binocular

• Accommodative

• Oculomotor

Dysfunction

Vision…Input abilities

• Binocular control

Ranges of fusion and integration with accommodation

• Accommodative control

Amplitude, flexibility/facility and integration with binocular control

• Oculomotor control

Fixations, pursuits and saccades

King-Devick

• Relationship between poor ocular motor abilities (ex. saccades) and reading efficiency

• Poorly on King-Devick are not efficient readers

• Saccadic eye movements can be improved with proper training

http://www.youtube.com/watch?feature=player_embedded&v=c4k9f2QL7KI

"Studies have indicated that the King-Devicktest is an effective tool for the real-time evaluation of concussion because it looks at rapid eye movement and attention, both of which are affected by concussions," said Dr. David Dodick, a neurosurgeon and the director of the Mayo Clinic's concussion program in Phoenix.

Mayo Clinic adds its name to sidelines concussion test

The King-Devick Test is a tool for evaluation of saccadic fixations, consisting of a series of test cards of numbers. The test cards become progressively more difficult to read due to variability of spacing between the numbers. Both errors in reading and speed of reading are included in deriving a score. Saccades are quick, simultaneous movements of both eyes.

King Devick website

King Devick website

What is Visual Fitness & How May It Be Affecting Your Life?

• Internet Eyes

• The Night-Driving Nightmare

• Counting the Pages

• Too Tired to Get a Life

• Sports Vision

• Wear Them—You’ll Get Used to Them

• Seeing to Sleep

• Developing Your Visual Fitness

9 WAYS PEOPLE CAN BENEFIT FROM VISION THERAPY

1) Improve vision related reading and learning problems

2) Improve vision in "lazy eye" - Amblyopia3) Correct cross or turned eyes – Strabismus 4) Enhance sports performance5) Aid people after a stroke or brain trauma 6) Myopia (nearsightedness) prevention, control,

and reduction programs7) Alleviate headaches from visual stress8) Help tired eyes in the workplace 9) Improve skills in visually delayed children

www.VisionHelp.com

Binocular Function

• State of simultaneous vision, which is achieved by the coordinated use of both eyes so that separate and slightly dissimilar images arising in each eye are appreciated as a single image by the process of fusion

• Achieved through a combination of stereopsis, ocular alignment & convergence

“Oculomotor dysfunctions are among the most common vision problems in individuals with acquired brain injury (ABI).a recent large-scale retrospectivestudy documented that approximately 90% of individuals with mild ABI or CVA manifested some type of oculomotor dysfunction after the acute phase of care.”

Ciuffreda KJ, Kapoor N, et al. Occurrence of oculomotor dysfunctions in acquired brain injury: a retrospective analysis.Optometry 2007;78:155-61

“There are an estimated 1,080,000 Americans that have experienced major disruptions in their professional and private lives because of vision changes resulting from a head injury.”

Stroke. 1997; 28:284-290

“Up to a quarter of stroke survivors may have vision dysfunction”

National Stroke Association

www.stroke.org

There is an extremely high incidence (greater than 50%) of visual and visual-cognitive disorders in neurologically impaired patients (traumatic brain injury, cerebral vascular accidents, multiple sclerosis etc.)

Rosalind Gianutsos, Ph.D.

Director, Cognitive Rehabilitation Services

Sunnyside, NY

A message from a TBI Survivor

“Society is more likely to take action against the ravages of traumatic brain injury if it understands how pernicious, pervasive and huge the problem is.”

Claudia L. Osborn, DO, FACOI

College of Osteopathic Medicine, Michigan State University

CDC 2013 Report to Congress

“Of the more than 2.5 million people experiencing TBI each year in the United States, it has been estimated that 75% experience mTBI”

According to the US Centers for Disease Control and Prevention

Mild traumatic brain injury (mTBI) is:

…”the occurrence of injury to the head arising from blunt trauma or acceleration or deceleration forces with one or more of the following conditions attributable to the injury: any period of observed or self –reported transient confusion, disorientation or impaired consciousness, dysfunction of memory around the time of injury, or loss of consciousness lasting less than 30 minutes.”

mTBI continued

• …“In addition, observed signs of injury to the head, irritability, lethargy, or vomiting following head injury, especially among infants and very young children; headaches, dizziness, irritability fatigue or poor concentration, especially among older children and adults”

VisionHelp TBI Concussion Video: https://www.youtube.com/watch?v=De0gMQ0Fd5U#t=25

The Ghost in My Brain: How a Concussion Stole My Life and How the New Science of Brain Plasticity Helped Me Get it Back•

• Clark Elliott, PhD

• Viking Press (June 2, 2015)

• Concussion after car rear-ended

• Overnight went from artificial intelligence professor to humbled man struggling to get through the day

• At times he couldn’t walk across a room, or even name his five children.

• Doctors told him he would never fully recover.

• After 8 years, cognitive demands of job & being a single parent, finally became more than he could manage

• Referred finally to 2 brilliant Chicago-area Clinicians—one an Optometrist specializing in Vision Therapy & the other a Cognitive Psychologist—working together on the leading edge of brain plasticity

• Within weeks the ghost of who he had been started to re-emerge

The Ghost In My Brain: The dramatic story of one man’s recovery offers new hope to those suffering from concussions and other brain traumas

Norman Doidge, MD :

The Brains Way Of Healing

"Related to natural vision therapy is the relatively unknown field of behavioral optometry, eye doctors who specialize in Vision Therapy, which for almost one hundred years has understood that vision is a group of skills that can be trained. The field relies on neuroplasticity.”

“The neurobiologist Susan Barry, Ph.D., spent fifty years with two-dimensional vision because she had strabismus - her eyes were misaligned ... With neuroplasticity-based training from her behavioral optometrist, Barry reawakened and rebalanced her visual cortex and finally experienced 3-D at the age of 50, as she compellingly described in her book Fixing My Gaze."

Archives of Physical Medicine and Rehabilitation

“Vision Therapy, Prisms, & Binasal Occlusion were very helpful in improving binocular integration, and double vision from extraocular movement disorders (in TBI patients).”

Reported in the March, 1998 Archives of Physical Medicine and Rehabilitation, Volume 79, No. 3 Suppl 1

"The ultimate purpose of the visual process is to arrive at an appropriate motor, and/or cognitive response. There is an extremely high incidence (greater than 50%) of visual and visual-cognitive disorders in neurologically impaired patients (traumatic brain injury, cerebral vascular accidents, multiple sclerosis etc.)"

Rosalind Gianutsos, Ph.D NeuroPsychologist

• "Visual-perceptual dysfunction is one of the most common devastating residual impairments of head injury". Barbara Zoltan, M.A., O.T.R.

• "The majority of individuals that recover from a traumatic brain injury will have binocular function difficulties in the form of strabismus, phoria, oculomotor dysfunction, convergence and accommodative abnormalities". William Padula, O.D. Neuro Optometrist

Visual midline shift syndrome[i]

Vision is normally matched with kinesthetic, proprioceptive and

vestibular function. Disruption in the coherence of these systems

can cause an individual to no longer visually judge objects that are

located along the patients anatomical midline, to be at their

anatomical midline.

[i] Padula, WV, Argyris, S. Post Trauma Vision Syndrome and

Visual Midline Shift syndrome. NeuroRehabilitation 6 (1996) 165-

171

Visual Midline Shift Syndrome(VMSS)

• occurs when the perception of a person's concept of visual midline shifts to the side

• causes the person literally to lean to the side, forward or backwards

• interferes with all aspects of balance, coordination and ambulation

Visual Midline Shift Syndrome (VMSS)

• A person's perception of his own midline shifts. • Walls may seem to lean in on him, and his

horizon may slant right or left. • This syndrome may cause dizziness or nausea,

spatial disorientation, and poor balance or posture as the person unconsciously leans to one side or the other to adjust to his perceived midline or horizon tilt.

• Effectively treated with yoked prisms & vision therapy

YOKED PRISMS SHIFT VISUAL-VESTIBULAR MIDLINE

Eye movement dysfunction

Fixation

Pursuits

Saccades

Nystagmus

Ocular muscle dysfunction

Pupillary defects

Ptosis

Lagophthalmos – poor closure of upper eyelid

Binocular dysfunction

Strabismus

Diplopia

Decreased depth perception

Exophoria

Convergence insufficiency

Vertical phoria

Accommodative dysfunction

Accommodative insufficiency

Perceptual dysfunction

Photophobia

Agnosia – problems recognizing familiar objects/faces

Visual memory

Visual attention

Visual-motor integration

Visual processing abilities

Cognitive deficits are worse when visual processing

problems are not identified or treated[i]

Visually induced balance dysfunction

Visual-vestibular integration

[i] Uzzell BP, Dolinskas CA, Langfitt TW. Visual Field Defecits in

Relation to Head Injury: A Neuropsychological Study. Arch Neurol

1988;45:420-424.

Post Trauma Vision Syndrome (PTVS) [i]

• Exotropia, Exophoria

• Convergence insufficiency

• Accommodative insufficiency

• Oculomotor dysfunction

• Double Vision, Headaches, difficulty maintaining eye contact

• Reduction or loss of one half or one quarter of the visual field

• Difficulty reading (words may appear to move, difficulty keeping

track of place on the page)

• Low blink rate, dry eyes, or staring behaviors [i] Padula, Argyris, Post Trauma Vision Syndrome and Visual Midline Shift

Syndrome. NeuroRehabilitation 6 (1996)165-171

PTVS Common symptoms

Diplopia

Blurred near vision

Perceived movement of print or stationary objects

Asthenopia

Headaches

Photophobia

Post Trauma Vision Syndrome & Vision Therapy

• Eye muscle imbalances & Eye alignment imbalances

• Ambient visual process dysfunction & sensory-motor spatial disorganization

• Eye turns outward or a strong tendency for both eyes to diverge. These binocular problems result in problems in balance, posture, attention, memory, reading difficulties, words appear to move, etc.

• Effectively treated with therapeutic lenses and vision therapy

Rehabilitation Professional’s Guide

• Post Trauma Vision Syndrome• Visual Midline Shift Syndrome• Dizziness• Double Vision• Spatial Disorientation• Hard to appreciate full screen of computer, TV,

movie• “I oftentimes feel like I’m going to fall”• “I get carsick & experience motion sickness”• “Reading gives me a headache, makes me feel

dizzy, sleepy”

Dizziness

A Patient Complaint That Can Make the Doctor’s Head Spin.

What Is Dizziness ?

• A non-specific term used to describe a number of signs and symptoms

– Unsteadiness

– Giddiness

– Light-headed

– Disequilibrium

– Vertigo

Dizziness, Hearing Loss, and

Tinnitus/ Baloh,R.W

1998,F.A.Davis Co

Focus of Diagnostic Workup

• Vertigo – auditory and Vestibular system

• Near-faint dizziness– cardiovascular system

• Psychophysiological dizziness - psychiatric

• Hypoglycemic dizziness- metabolic assessment

• Disequilibrium – peripheral nerves, spinal cord, inner ear, vision, CNS

History of the Dizzy Patient

• Detailed description of dizziness

• Differentiate vertigo from non-vertigo

• Determine onset, length, and if recurrent

• Associated neurological or systemic signs

• Any hearing loss?

• Current medications

• Differentiate Peripheral vs. Central cause

Differential Diagnosis and

Management for the Chiropractor,

Aspen Publishers, Inc 2001

Peripheral or Central Cause?

Peripheral

• Labyrinth or vestibular nerve dysfunction

• Recurrent

• Nystagmus-horizontal

• Position change

• Moderate to severe vertigo

Central

• Cerebellum or brain stem dysfunction

• Continuous

• Nystagmus-vertical

• Mild vertigo

• Non-positional

Assessment of the dizzy patient,

Australian Family Physician Vol.

31, No. 8, August 2002

Peripheral Vestibular Disorders

• BPPV

• Labrynthitis

• Meniere’s disease

• Acoustic Neuroma

• Motion sickness

• Cervicogenic

• Perilymphatic fistula

• Vestibular neuronitis

• Semicircular canal infection

• Semicircular canal water penetration

Assessment of the dizzy patient,

Australian Family Physician Vol.

31, No. 8, August 2002

Central Vestibular Disorders

• Brain stem lesion

• Basilar artery migraine

• TIA

• Stroke

• MS

• Cerebellar lesions

• Metastatic Tumor

• Meningioma

Assessment of the dizzy patient,

Australian Family Physician Vol.

31, No. 8, August 2002

Central Vestibular Disorders

• Brain stem lesion

• Basilar artery migraine

• TIA

• Stroke

• MS

• Cerebellar lesions

• Metastatic Tumor

• Meningioma

Causes of Vertigo

• Ear disease

• Toxic conditions (alcohol, food poisonings)

• Postural hypotension

• Infectious disease

• Cervicogenic

• Disease of the eye or brain

• Psychological

Australian Family Physician Vol.

31, No 8, August 2002

When to refer to a specialist

• Serious vertigo that is disabling

• Ataxia out of proportion to vertigo

• Vertigo longer than 4 weeks

• Changes in hearing

• Vertical nystagmus

• Focal neurological signs

• Systemic disease or psychological origin

A Neuro Optometrist’s Perspective

The difference between

eyesight and vision

-Eyesight is the ability to see clearly at 20 feet.

-Vision goes far beyond simply this.

The Autistic Spectrum of Disorders (ASD) from least to most serve:

• ADD (Attention Deficit Disorder)

• ADHD (Attention Deficit Hyperactivity Disorder)

• LD (learning disabilities)

• NLD (non-verbal learning disabilities)

• HFA (high functioning autism)

• AS (Asperger Syndrome)

• PDD (pervasive developmental disorders)

• PDD-NOS (PDD not otherwise specified)

• Autism

Lorna Wing, MD “The Autistic Spectrum”

Patients with Autistic Spectrum Disorders (ASD) have a high incidence of:• Strabismus

• Hyper & Hypo reactivity to information coming in from their touch, movement, & vestibular system

• Gross & Fine Motor Delays

• Evidence of retained primitive reflexes

Signs of Visual Problems in Individuals with ASD

• Squints or closes one eye

• Stares at certain objects or patterns

• Looks through hands

• Flaps hands, flicks objects in front of eyes

• Sensitivity to light (photophobia)

• Looks at objects sideways or with quick glances

Signs of Visual Problems in Individuals with ASD continued…

• Pushes or rubs eyes

• Confused at changes in flooring or stairways

• Difficulty making eye contact

• Bumps into objects

• Widens eyes or squints when asked to look

• Touches walls/tables while walking

• Obsession with lights & shadows

ASD & Central/Peripheral Vision Coordination

• Children with autistic spectrum disorders tend to use one or the other…not both simultaneously

• Central (focal) Processors can fixate on a central point of focus for excessive periods of time…obsessed with details, staring at a stick in their central field

• Peripheral (ambient) Processors can spend hours staring at high contrast, moving, lights, shadows, shiny objects

Poor Integration of Central/Peripheral Vision can lead to…

• Difficulties in focusing, attention, spatial organization, and visual perception

• Developing compensatory techniques to deal with their faulty view of the world like toe walking, walking while touching or holding onto walls, hand flapping

Kids' eye problems often emerge in homework battleNew Research on Convergence Insufficiency (CI)

Archives of Ophthalmology October, 2008;126(10):1336-1349

NIH funded

Multi Million Dollar, Multi Center

Placebo Controlled

Definitive relationship between CI and ADHD

The Vestibular System

In essence,the vestibular system

is the orienting system

for the

auditory and visual systemsin time and space

The Vestibular System

A motor center to move around three dimensionally.

An emotional center for self-regulation

A perceptual center so we are notlost in space.

A spatial-temporal center with which to relate to objects, people, and events in our world.

Visual Dysfunctions Causing Dizziness & Balance Problems

• Aneisokonia

• Vertical Imbalance

• Binocular Vision Dysfunction

• Double Vision

• Ambient Visual Disorder

• Eye Movement Disorders

Visual field Deficits

• Occur in about 40 % of patients with TBI

• Occur in about 67 % of patients with CVA

Cerebral Vascular Accident & most (30 %) are homonymous

Therapeutic interventions for visual dysfunction

Patching

Selective sector

Opaque

Translucent

Lenses

Prism

Fresnell

Ground in

Yoked[i]

Tints

Refractive error

[i] Rossetti, Y, Rode, G, Pisella, L, Farne, A, Li, Boisson, D, Perenin, M-

T. Prism Adaptation to a Rightward Optical Deviation Rehabilitates Left

Hemispatial Neglect Nature Vol 395 Sep 1998; 166-169

Field awareness prism[i]

Spot

Ribbon

[i]Gottlieb, DD, Fuhr, A, Hatch WV, Wright, KD, Neuro-

optometric Facilitation of Vision Recovery After Acquired Brain

Injury NeuroRehabilitation 11 (1998) 175-199

Vision Rehabilitation[i]

Hemianopsia treatment protocol

Binocular fusion therapy

Ocular motility therapy

Visually guided movement

[i] Raymond, MJ, Bennett, TL, Malia, KB, Bewick, KC.

Rehabilitation of Visual Processing Deficits Following Brain Injury.

NeuroRehabilitation 6 (1996) 229-240

Impairment Disability

• Hemianopsia

• Diplopia

• Visual Midline Shift

• Poor saccades

• Slow visual-motor response

• Shop in mall

• Dial phone

• Walks into furniture

• Difficulty reading

• Unable to drive

Vision Therapy at San Diego Rehabilitation Institute

http://youtu.be/vUIjLoNaZFE

Visual Vestibular

Therapy

A Review of the Latest Research into Vision Therapy

• Archives of Ophthalmology 2005; 123:437-447: NIH study confirms “it is never too late to treat a “Lazy eye with vision therapy”

• Archives of Ophthalmology 2005; 123:14-24: Controlled Study Demonstrates Value of Optometric Vision Therapy

Strabismus, December, 2005; 13 (4): 163-168New Research study confirming link between Binocular Vision Problems and ADHD

• Learning Disabilities Association Journal, 2004: Article Shows Benefits of Vision Therapy

• Journal of Learning Disabilities, Nov. 2003: Vision Therapy improves Reading Comprehension

www.visionhelp.com

Plasticity

• “Recent evidence from a number of state-of-the-art laboratories for neurobiology indicates that visual, tactile, and motor systems remain modifiable to a significant degree well into adulthood.” – Thomas Albright, Ph.D The Salk Institute For

Biological Studies

USA TODAY January 27, 2011

'Happy that I'm still alive'

Wounded veteran Patrick Horan works with Dr. Bryce Appelbaum as Horan's wife, Patty, looks on during vision

therapy in Bethesda, Md www.USAToday.com

What is vision therapy?

Is it strength training for the eyes?

Well, not exactly…

Vision Therapy and Rehabilitation

What is vision therapy?

“Vision therapy is a sequence of neurosensory and neuromuscular activities individually prescribed and monitored by the doctor to develop, rehabilitate and enhance visual skills and processing.”

- American Optometric Association

“Unlike other forms of exercise, the goal of optometric vision therapy is not to strengthen eye muscles.”

-College of Optometrists in Vision Development

What is vision therapy?physical & occupational therapy for the eyes with a cognitive component

Our Population

We primarily treat

• Children with ADHD• Mild traumatic brain injury/concussions• Learning and reading disabilities (reluctance to read)• Autism Spectrum Disorder

Vision Therapy- Delivery of care

• Office-based

• Provided by a Doctor of Optometry –

Doctor is in the therapy room

• Board Certified, FCOVD

– Vision therapy assistants

• Generally 50 minute sessions- 1-2 x/week

• Home reinforcement

Duration of treatment

• Based on diagnosis

• Complicating factors

Lenses and Prisms

Lenses• The role of the lens

– Refractive correction-

– Aid accommodation-• Influence binocular vision via AC:A

– Aid spatial awareness

– Aid peripheral awareness

– Aid focal-ambient integration• http://maunsell.med.harvard.edu/Downloads/publications/87bMaunsell.pdf

• http://www.oepf.org/jbo/journals/2-1%20Marrone.pdf

Prisms – Vertical & Horizontal

Yoked Prisms

Chairside Screening

• What gets tired first, your eyes or your body ?

• Reluctant or Avid Reader ?

• King-Devick Concussion Screening Eye Movement Test

Southern College of Optometry Residency in Vision Therapy and Vision Rehabilitation in a Private Practice

• Only fully accredited Optometric Residency in the Washington, DC area

is at AppelbaumVision.com

Bethesda & Annapolis, Md.

• Stan Appelbaum, OD, FCOVD Supervisor

• Thanks for referring interested OD students

• Vision Rehabilitation: Multidisciplinary Care of the Patient Following Brain Injury –edited by Suter & Harvey (2011)

Vision Therapy

• Brock String

• Matrix

• Thumb Rotations

• Three Thumbs

• Red/Green Flashlight

• Peripheral Vision Expansion

Huang JC. Neuroplasticity as a Proposed Mechanism for the efficacy of optometric therapy & rehabilitation.J Behav Optom 2009; 20(4):9-99.

• The scientific community is gradually embracing the notion that rehabilitation of motor, sensory and cognitive impairments can alter brain reorganization and result in functional recovery.

• The training and rehabilitation of functional visual disorders through repetitive, targeted visual rehabilitative techniques should not be a foreign concept.

• Based on what is now known about neuroplasticity, the mechanism for the efficacy of VT and rehabilitation is likely through strengthening synaptic connections and inducing cortical reorganization to maximize visual efficiency.

Brain Injury Medicine: Principles and Practice

Nathan D. Zasler

Douglas I. Katz

Ross D. Zafonte

Demos Medical

Publishing 2006

p. 511-528 “Evaluating & Treating Visual Dysfunction,” Padula, Wu, Vicci

EYE POWER . . . a cutting edge report on VISION THERAPY

Ann M. Hoopes &Stanley A. Appelbaum, OD, FCOVD

Improve your visual attention, vitality, stamina,

mental efficiency, and productivity for a better quality of life.

www.EyePowerBook.com

Resources

Neuro-Optometric Rehabilitation Association

www.nora.cc (NORA)

VisionHelp Network

www.VisionHelp.com

Because…life takes vision

Questions? Contact:Stan Appelbaum, OD, FCOVD

Bryce Appelbaum, OD, FCOVD

Barbara S. Bassin, OTR/L, BCP

Sensory Integration & Vision Therapy Specialists

Bethesda & Annapolis Maryland

301-897-8484

www.VisionHelp.com

www.AppelbaumVision.com