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/ontario@2x-print.png

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/ontario@2x-print.png. 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.