Overview

Traumatic brain injury or a cerebrovascular accident is sudden and devastating. Research performed by Dr. Padula and others has shown that often there are visual problems which occur after a head injury or cerebrovascular accident that can interfere with balance, movement, coordination, attention, concentration, and reading ability. Frequently, persons who have had a traumatic brain injury, cerebrovascular accident or other neurological problems will experience double or blurred vision, blind spots, dizziness (vertigo), movement of the floor and/or other stationary objects, and in some cases even hallucinations. Dr. Padula has named this particular type of vision problem that occurs after a traumatic brain injury or cerebrovascular accident (Padula) Post Trauma Vision Syndrome. If untreated, this syndrome can, in many cases, greatly interfere with rehabilitation of cognitive and neuro-motor function.

A Neuro-Optometric Rehabilitation evaluation provides information for analysis of the profound relationship of the visual process to balance, posture, movement, position sense, cognitive processing and memory. The evaluation includes a careful analysis of how the person uses a portion of the visual system, the ambient visual process, to support balance and posture. After a traumatic brain injury or cerebrovascular accident, instability that occurs in this peripheral vision system causes interference with fixation, tracking, focusing, and eye teaming (use of the two eyes together).

Physical Disabilities

Whether a person has a physical disability caused by a traumatic brain injury, cerebrovascular accident, cerebral palsy, autism, multiple sclerosis or other congenital or acquired neuro-motor problems, visual imbalances and distortions can actually reinforce the particular physical disability. It has been found that frequently a neuro-motor disability will cause a shift in the perceived concept of the child’s or adult’s awareness of their visual midline. The visual midline is produced by the matching of visual information with sensory-motor information to give the person an awareness of the center of their body.

A shift of the visual midline is caused by a dysfunction of the ambient visual process. It has been called The (Padula) Visual Midline Shift Syndrome. This midline shift reinforces postural imbalances causing the person to lean to one side, forward (flexion), or backward (extension) because the concept of visual midline is displaced. Therapeutic use of lenses and prisms can help to stabilize the disrupted peripheral or ambient visual process. Through use of special yoked prisms the visual concept of midline can be reoriented, thereby resulting in improved posture and balance. The use of these therapeutic yoked prisms has also been found to affect the physical state of muscle spasticity. The use of special lenses, yoked prisms and/or other optical aids is not meant to take the place of physical or occupational therapies. Instead, these devices are often recommended to be used in conjunction with these therapies. Through a multi-disciplinary approach of using therapeutic lenses and/or yoked prisms it has been found that the rehabilitation of the physically disabled child or adult can be more complete and efficient, enabling the person to achieve a greater potential in the least amount of time.

Mr. L. was referred for a Neuro-optometric rehabilitation examination by doctors from a rehabilitation hospital.  He suffered a severe whiplash when his automobile was struck from behind. He is 45 years old and he was in normal health prior to his injury.

Initially, Mr.L. was taken to a hospital but was not admitted. Within 24 hours of the accident he lost the ability to balance and began to have significant speech and cognitive function problems.  Physical and occupational therapy were initiated but his progress remained limited.

Mr. L. was unable to respond to most of the questions asked of him but appeared to stare at the examiner and looked to his wife in order to ask her to help him respond to the questions.  His entering visual acuity with best distance correction was 20/60 right eye, left eye and both eyes.  He had a very difficult time developing pursuit tracking and demonstrated facial contortions, like squinting that indicated that he was in considerable discomfort when attempting to track an object toward his face.

The examination determined that he had the characteristics of Post Trauma Vision Syndrome which included a variety of vision disfunction (convergence insufficiency, accommodative dysfunction, oculomotor dysfunction, and photophobia (glare sensitivity).  Upon treating him, using his habitual distance correction and adding low amounts of base in prism and binasal occlusion, his distance acuity responded within minutes and improved to 20/25 right eye, left eye and both eyes.  Improvements were also demonstrated in his ability to track objects and to improve fixation on an object moved toward his face without losing eye alignment and without experiencing the excessive discomfort and eye strain.  

Speech patterns also began to improve as his discomfort minimized, and he was able to answer questions.  He reported that he was frequently having double vision but that with the lenses and occlusion he experienced a singular binocular world that slowly improved in three dimensions, enabling him to perceive depth in his environment.

It was also determined that he had a significant shift in his concept of visual midline to the right.  When walking, he leaned heavily to the right and began to drift to the right while scissor-stepping across with his left foot.  Utilizing an additional yoked prism to shift the midline back to center, he was immediately able to weight bear on his left side while walking in a straight line and maintaining his balance and posture.  Prism glasses were designed for him for use full time and separate therapeutic yoked prisms were designed to be used in conjunction with physical therapy.

Mr. L. returned to the hospital where he was an inpatient and continued rehabilitation through prescribed physical, occupational and cognitive rehabilitation programs.  The reports from the therapists documented the significant improvement with balance, ambulation, attention and concentration. He returned for a follow-up visit six weeks thereafter.  He reported that he had been discharged from the hospital and was an outpatient.  His speech patterns and cognitive functioning had improved. His balance also had improved considerably. He continued to use the yoked prisms for the prescribed two hours per day.

Neuro-Optometric Rehabilitation Association Definition of Neuro-Optometric Rehabilitation

Neuro-optometric rehabilitation is an individualized treatment regimen for patients with visual deficits as a direct result of physical disabilities, traumatic brain injuries, and other neurological insults. Neuro-optometric rehabilitative therapy is a process for the rehabilitation of visual, perceptual, and motor disorders. It includes, but is not limited to: acquired strabismus, diplopia, binocular dysfunction, convergence and/or accommodation paresis/paralysis, oculomotor dysfunction, visual-spatial dysfunction, visual perceptual and cognitive deficits, and traumatic visual acuity loss.

Patients of all ages who have experienced neurological insults may require neuro-optometric rehabilitation. Visual problems caused by traumatic brain injury, cerebrovascular accident, cerebral palsy, Multiple Sclerosis, etc., may interfere with performance causing the person to be identified as learning disabled or as having attention deficit disorder.  These visual dysfunctions can also manifest themselves as psychological sequelae such as anxiety and panic disorders, as well as spatial dysfunctions affecting balance and posture.

A neuro-optometric rehabilitation treatment plan is designed to improve specific acquired vision dysfunctions determined by standardized diagnostic criteria. Treatment regimens encompass medically necessary non-compensatory lenses and prisms with and without occlusion, and other appropriate medical rehabilitation strategies.

Types of Problems Frequently Treated:

• Aging And Risk Of Fall
• Attention Deficit Disorder (ADD)
• Autism (ASD)
• Cerebral Palsy
• Concussion (Traumatic Brain Injury – TBI)
• Lyme Disease
• Parkinson’s Disease
• Stroke (CVA)

It is recommended that the draft manual be adapted to include the following:

1. that dysfunction of the visual process can occur with both open as well as closed head injuries;
2. that vision dysfunction following a TBI often includes diplopia, photophobia, exotropia, convergence insufficiency, accommodative dysfunction, oculomotor dysfunction, scotoma, anisiekonia, cortical vision impairment, and that these visual problems often interfere with rehabilitation programs attempting to affect cognitive function, balance, concentration and attention;
3. that vision be defined in order to avoid confusion in rehabilitation as “vision is a dynamic, interactive process of motor and sensory function mediated by the eyes for the purpose of simultaneous organization of posture, movement, spatial orientation, manipulation of the environment and, to its highest degree, thought”;
4. that appropriate vision rehabilitation be incorporated as part of the multidisciplinary team to potentially increase the effectiveness of other rehabilitation programs thereby reducing the long term costs to insurance, third party reimbursement and private payers;
5. that grant monies should be earmarked to develop research concerning dysfunction of the visual process following TBI and that the research should be linked with educational programs to make the research clinically applicable.

Neuro-Optometric Rehabilitation (Vision Rehabilitation) for Persons with Traumatic Brain Injury

Presented at the National Institutes of Health Consensus Development Conference Rehabilitation of Persons with Traumatic Brain Injury October 26-28, 1998 Natcher Conference Center Bethesda, Maryland by William V. Padula, O.D., F.A.A.0.

My name is Dr. William Padula. I am an optometrist who practices neuro-optometric rehabilitation. I am the founding president of the Neuro-Optometric Rehabilitation Association, International and I am on staff at the Hospital for Special Care, Rehabilitation Hospital of Connecticut and Gaylord Rehabilitation Hospital in Connecticut. Also, I am the director of the Easter Seals Rehabilitation Center Vision Rehabilitation Service of New Haven and Hartford, Connecticut. It is my intention to speak to you today about the need for visual rehabilitation of individuals who have had a traumatic brain injury.

Persons who have experienced a traumatic brain injury frequently will have vision problems that cause a wide range of symptoms 1.2 -” The symptoms include diplopia (double vision), photophobia (glare sensitivity), difficulties with reading causing the print to appear in and out of focus as well as seeing words moving about the page, headaches and eye strain. These symptoms are well documented in the literature related to binocular vision disorders such as convergence insufficiency, accommodative insufficiency, oculomotor dysfunction, and photophobia. It has traditionally been thought that visual problems can only occur with open head injuries.’ More recent literature and clinical findings from many optometrists practicing neuro-optometric rehabilitation have determined that this is untrue. In fact, most individuals who have suffered a closed head injury and/or whiplash can experience visual disorders that directly interfere with function and performance as well as the ability to progress in prescribed rehabilitation programs including physical, occupational, speech and cognitive therapies.

Recent research has documented that there are two separate visual processing systems. One system which is more related to the occipital cortex in function analyzes and searches for detail. This system is termed the focal visual process and is related to visual acuity. The second visual processing system is termed the ambient system. Information from the eyes is delivered to levels of midbrain to match up with other sensory-motor systems for the purpose of establishing spatial function related to posture, balance, movement and ambulation. It is this second visual processing system, the ambient process, that is often affected following traumatic brain injury as well as whiplash. The dysfunction involving this portion of the visual process directly interferes with the ability to organize and orient in the environment spatially. Dysfunction of the ambient visual process interferes directly with binocular vision function. The result can cause one of two syndromes: Post Trauma Vision Syndrome or Visual Midline Shift Syndrome.

Post Trauma Vision Syndrome (PTVS) has been documented by conducting brainwave studies (visual evoked potentials) of the visual cortex’. Research shows that the amplitudes of wave patterns (P100) are greatly diminished, indicating reduced function. When using prisms and occlusion the amplitudes increased, indicating that the ambient visual process became re-balanced and resulting in improved visual function. In many cases, the almost immediate increase in the VEP amplitude is accompanied by a reduction in the characteristic symptoms of Post Trauma Vision Syndrome which include headaches, eye strain, difficulties with reading, problems with attention and concentration and disorientation.

Visual Midline Shift Syndrome (VMSS) occurs when the perception of a person’s concept of visual midline shifts to the side. This causes the person literally to lean to the side, forward or backwards. This interferes with all aspects of balance, coordination and ambulation. Treatment has been developed through the use of yoked prisms to shift the midline back to center. Dramatically, in many cases individuals will begin to not only establish improved balance, but in cases of hemiparesis or hemiplegia, will even begin to weight bear on their affected side.

Neuro-optometric rehabilitation is defined as “an individualized treatment regimen for patients with visual deficits as a direct result of physical disabilities, traumatic brain injuries, and other neurological insults. Neuro-optometric rehabilitation therapy is a process for the rehabilitation of  visual/perceptual/motor disorders. It includes, but is not limited to: acquired strabismus, diplopia, binocular dysfunction, convergence and/or accommodation paresis/paralysis, oculomotor dysfunction, visual-spatial dysfunction, visual perceptual and cognitive deficits, and traumatic visual acuity loss.” (See Appendix A)

Persons who have suffered a traumatic brain injury and who have visual dysfunction from Post Trauma Vision Syndrome and/or Visual Midline Shift Syndrome are at a great handicap when attempting to perform other prescribed therapies. Conditions of diplopia, convergence insufficiency, accommodative dysfunction and visual midline shift will directly interfere with the prescribed therapies and frequently cause the therapist to document in their records that the person has plateaued and will not make any further progress. It has been found that by integrating neuro-optometric rehabilitation into the multi-disciplinary services of rehabilitation, visual problems can be diminished, thereby enabling other therapies to be more successful. For example, a person who has experienced a traumatic brain injury with a resulting hemiparesis will frequently have a visual midline shift syndrome. By prescribing the appropriate yoked prisms to bring the visual perception of midline back to center, increased weight bearing can be developed on the affected side. These prisms may be used in a transdisciplinary approach in physical therapy, enabling the therapist to maximize the potentials beyond those which could be established without the use of yoked prisms.

As representative of the Neuro-Optometric Rehabilitation Association, I have been asked to emphasize that insurance companies, the federal government, private insurance companies, and families are spending extraordinarily large sums of money for rehabilitative services which do not include neuro-optometric rehabilitation. The end result is that many individuals do not maximize benefits from these therapies and are placed in compensatory living situations and/or limited skill environments which are usually also expensive to the system in general. Frequently, these patients have been referred to optometrists practicing neuro-optometric rehabilitation months or even years after all other treatments have stopped. Once the appropriate diagnosis and treatment regimen is established for vision rehabilitation, persons will frequently make progress again with visual function affecting the ability to read, balance and ambulate. It then becomes necessary to recommend that the rehabilitation process begin all over again for physical, occupational, speech and cognitive therapies. The Neuro-Optometric Rehabilitation Association International strongly recommends that appropriate vision rehabilitation, evaluation and treatment be incorporated into the existing multi-disciplinary evaluation and rehabilitation team. This will not only maximize potentials for the individual and improve success rates in therapy programs, but will also considerably reduce costs of therapies since many of the problems of the individual are related to visual processing difficulties.

Mr. Chairman and distinguished members of the panel, I cannot overstate the necessity of including vision rehabilitation in the rehabilitation model of persons with traumatic brain injury. The American Academy of Physical Medicine and Rehabilitation has acknowledged the importance of diagnosing Post Trauma Vision Syndrome and has cited this research in their 1998 study guide for all member physicians. If I had the opportunity of more time to show videotapes of patients, I would be able to demonstrate to you the often dramatic results of rehabilitating the visual process in its relationship to performance and function. I have included in my written comments a case study (see Appendix B) of an individual who suffered from both Post Trauma Vision Syndrome and Visual Midline Shift Syndrome. I ask that you spend five minutes to review this case study in order that you might more fully understand the implications of these visual problems affecting individuals who have had traumatic brain injury.

In conclusion, vision is the primary sensory process and when the process is disrupted by traumatic brain injury, it will interfere with recovery and the ability to progress in prescribed rehabilitation programs. The result is lost time of employment, quality of life and substantial sums of money for rehabilitation being wasted if neuro-optometric rehabilitation services have not been integrated into the multi-disciplinary team approach. Vision dysfunction can occur from open head injury as well as closed head injury. The Neuro-Optometric Rehabilitation Association International respectfully requests that the draft document produced by this committee be altered to include this fact and to emphasize the need to include neuro-optometric rehabilitation into the multidisciplinary model of rehabilitation. While the committee has identified all of the rehabilitation service needs of the person with a traumatic brain injury (i.e. physical, occupational, speech, cognitive rehabilitation therapy, psychological counseling, etc.) vision has only been mentioned in passing within different areas of the manual. It needs to be identified, documented and referenced in relationship to the overall rehabilitation of the patient. In addition, there is a need to develop research to study this important area of vision and vision rehabilitation more closely as well as to examine its potential to reduce costs to federal and third party reimbursement programs.