Case Study: Angie
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Transcript of Case Study: Angie
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Case Study: Angie Motor Vehicle Accident TBI:
Damage to the frontal lobe, bi-temporal, bi-parietal and occipital craniotomy
Left Homonymous Hemianopia
Left Inattention Visuo-spatial deficits Visual processing deficits Left Hemiparesis
Memory
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Barriers Denial of any deficits – Anosagnosia Left Lower Quadranopsia – both eyes Left Neglect (Reading/Scanning) Memory issues Standing Balance poor Walking balance poor
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Pen and Paper TasksTransfer of scanning skills to table top tasks.
Systematic scanning pattern Smooth scanning across a line in preparation for reading
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NVT Static Scanning Sitting Standing
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Step by step methodology in the transfer of scanning skills to mobility tasks in a graded fashion in a client’s local community.
Transfer to Independent Walking and Scanning
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Transfer from walking frameto support cane.Ensuring balance, gait and Scanning skills are not Compromised.
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Residential Scan – DrivewaysUnilateral Scanning to LEFT
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Static and Dynamic Scanning for moving targets
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SUPERMARKET TRAINING:Transferring scanning skills intoEveryday community settings.Preparation for independent living.
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Transition -scanning to street crossing
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Business Area
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Progression into Community – O&M
Visual Scanning strategies continue to Residential – Light Business area – street crossing
Increase multiple-stimuli in all environments Decrease use of Cues and Prompts At times, distract patient while on task by
talking to them and observe if they stay “on task”
If consistent problems in dynamic environment (i.e.: proper scanning patterns), increase therapy sessions in static environment (i.e.: static visual scanning exercises)
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Timeline of Events - Angie
June 20, 2006 MVA accident admitted to hospital in ITALY July 6, 2006 Transferred to Landstuhl, Germany Military
Medical Center July 7, 2006 Transferred to Bethesda NMC July 22, 2006 Admitted Palo Alto VA Polytrauma
Rehabilitation Center
September 22, 2006 Discharged from PRC; housed in community for continued outpatient
rehabilitation services October 24, 2006 Admitted to Brain Injury Rehabilitation Unit
(BIRU), Post-Acute Transitional Rehab.
March 15, 2007 Discharged from the Air Force
May 23, 2007 Discharged from the Brain Injury Rehabilitation Unit per trainee request
June 27,2007 Purchased House in Texas near family and living independently, Attending University but having
difficulty in remembering so much information
Total VA Rehab. Timeline: Acute Rehab – 4 months -- Post Acute Rehab – 5
months
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Types of Electronic devices for visual search/scanning activities
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Mr. P IED blast in Iraq 10-20-2006 Moderate TBI, LOC noted Tunnel vision underwent emergent right occipital and
posterior fossa craniectomy
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Mr. P visual field report <5 degrees
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Progression of Visual Scanning – Tunnel vision OU
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Mr. S 63 yr old vet with history of mild TBI
sustained in Vietnam
Well-compensating for years
Recently (past 8 months to 1 year) has had increased vertiginous symptoms w/ dizziness
Increased difficulty with visual attention, specifically blurring of vision when concentrating on fixed objects
Difficulty with keeping head upright and
visual scanning causes vet to lose balance
Plate in neck fusing vertebrae and increased pain from looking down so often
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Mr. S Vision Rehab 12 sessions total 1x per week 1 hr lesson Static scanning White cane training to
improve head up positioning
Lessons range from static to dynamic
Roller tip and bandu basher cane tips
Rural area training
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ddd
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Mr. S Income/Outcome Dynavision (D2) measure
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Meet Doug
• 45 year old Army Ranger• TBI exposure• Temporal/Frontal Lobe
atrophy
• Motor apraxia (neck and left hand)
• Visual Field constriction OU
• Sees Pictures that persist: -Palinopsia ?• Slow visual processing
• Auditory: Tinnitus • PTSD
• MRI findings: microvascular disease, temporal, frontal lobe atrophy
Title
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• Major Visual complaint: Patient verbalizes
• Not able to see motion (visual processing)• Sees pictures that persist, some frames empty• Tunnel vision• Extreme Photosensitivity• Blurred vision
• Vision Testing:• No prior ocular disorders• 20/20 OU Distance• 20/20 OU Near (with +1.50 Readers OU)• Confrontation Visual Fields difficult to assess with motor
apraxia• Fixation: 3 seconds before tics• Midline shift testing – wnl• Unable to determine:
• EOM, NPC, Sacc, Pursuits, stereo
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• Audiology referral• Tinnitus Masker• Filters “white noise” in
environment
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Orientation & Mobility Goals
• Dual Cane travel• Hallway travel with crowds• Independent residential
travel• Improve response time• Improve auditory awareness • Improve auditory localization• Establish rest break/coping
with crowds/excess noise• Visual Scanning/Maintain
Eye level • Differentiating auditory
stimulus vs. visual images• I.e.: hearing vs. seeing
car first
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Recreation Needs
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VA On-line Resources www.tbiguide.com Nora website: www.nora.com http://www1.va.gov/netsix-braininjury/ CBIS (Certified Brain Injury Specialist) www.Bernell.com National Wheelchair Olympics in Richmond June
25-30th !! HTS Home Therapy System Neurovision Technologies Dynavision D2 Wayne Engineering Products
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References1. Kerkhoff, G. “Neurovisual rehabilitation: recent developments and future directions.” J. Neurol. Neurosurg. Psychiatry 2000;68:691-
706. 2. Verlander, D. et al. “Assessment of clients with visual spatial disorders: a pilot study” Visual Impairment Research, 2000, Vol 2,No 3,
pp 129-142. 3. Zihl, J. “Ocular scanning performance in subjects with homonymous visual field disorders”, Visual Impairment Research, 1999, Vol.1,
No.1, pp 23-31.4. Parton, A. “Hemispatial neglect” J. Neurol. Neurosurg. Psychiatry 2004;75;13-21.5. Goodrich GL, Kirby J, Cockerham G, Ingalla SP, Lew HL. Visual Function in Patients of a Polytrauma Rehabilitation Center: A
Descriptive Study. Journal of Rehabilitation Research & Development. in press.6. Taber KH, Warden DL, Hurley RA. Blast-Related Traumatic Brain Injury: What Is Known? J Neuropsychiatry Clin Neurosci.
2006;18(2):141-5.7. TBI Survival Guide – Dr. Glen Johnson -- www.tbiguide.com 8. NeuroVision Technologies South Australia -- www.nvtsystems.com9. Kerkhoff G, MunBinger, U, haaf E, Eberle-Strauss G, Stogerer E. Rehabilitation of homonymous hemianopsia scotomata in patients
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36.13. Ishiai S, Furukawa T, Tsukagoshi H. Eye fixation patterns in homonymous hemianopsia and unilateral spatial neglect. Neuropsychologia
1987; 25:675-7914. Zihl, J. Visual scanning behaviour in patients with homonymous hemianopia. Neuropsychol 1995; 33: 287-30315. Chedru F, Leblanc M, Lhermitte F. Visual searching in normal and brain damaged subjects. Cortex 1973;9: 94-111.16. Poppelreuter W. Die Storungen der Niederen und Horeren Schleistungen durch Verletzungen des Okzipitalhirns. 1917.
17. Zangemeister WH, Meienberg O, Stark L, Hoyt WF. Eye head coordination in homonymous hemianopia. J Neurol 1982; 226: 243-54 18. Zihl, J. Eye movement patterns in hemianopic dyslexia. Brain 1995; 118: 891-912. 19. Dynavision D2, Neurovision Technology Systems, Wayne Saccadic Fixator, Hart Chart, Home Therapy System, (HTS), Parquetry,