Introduction - TIRR • The Institute for Rehabilitation of Patients Rehabilitation and Research – In-patient & with Acquired Brain Injury Out-patient Programs • Ranked within the top 5 rehabilitation hospitals in Kia B. Eldred, OD, FAAO, the US for 20 years Diplomate in Low Vision • Affiliation with University of Michael E. DeBakey VA Medical Center Houston College of University of Houston College of Optometry Optometry for 23 years Michael E. DeBakey HVAMC & Project Victory Categories of Brain Injuries • ~30,680 US soldiers wounded in Iraq & • Traumatic Brain injury Afghanistan – TBI is the “signature wound” • Non- traumatic brain injury – 20% of injuries are serious ABI or SCI – 1800 troops suffering from penetrating TBI • Now defined as “Acquired” (ABI) –> – 3000 soldiers being treated for severe TBI Includes stroke – 30% of troops engaged in combat > 4 – Ischemic: 80% months are at risk for disabling neurologic disorders from blast waves of IEDs – Hemorrhagic: 20% – 60% of injuries are due to roadside bombs & IEDs (improvised explosive devices) – 30% of soldiers develop mental health problems (PTSD) within 3-4 months of returning to the US Shearing & Traumatic Brain Injury Contusions • Closed head injury – denotes that the dura remains intact • Open head injury – denotes that the dura was opened • Penetrating head injury – denotes that a foreign object penetrated the dura and entered the brain http://www.biak.us/images/brain2.jpg http://www.doctorlawyer.net/images/ClosedHeadInjury.jpg 1 Subdural & Epidural Hemorrhages Non- traumatic Brain Injury • Anoxic Brain Injury – decreased oxygen supply to the entire brain – major cause is cardiac arrest • Toxic-metabolic Brain Injury – caused by industrial solvent exposure and hepatic encephalopathy Blast Injury Primary Blast Injury • Caused by barotrauma • Primary • Barotrauma (blast waves) – Overpressurization from blast wave followed by immediate underpressurization • Secondary • metal fragments, penetrating projectiles – Peak pressure reached in a few microseconds • Displacement of entire body by • Tertiary combined pressure loads (shock waves) – Pressure decreases exponentially in time over a pulse duration typically less than two • Miscellaneous: burns, toxic inhalation, milliseconds • Quartenary crush injuries Damage to General Areas of the Damage to General Areas of the Brain Brain • Frontal • Occipital – Disinhibition/emotions – Cortical visual • Brainstem • Cerebellum – Reasoning impairment / blindness – Balance – Coordination of – Saccadic control – Homonymous field – Cranial nerves movement – Reduced blink rate defects associated with EOMs, – Disturbances in visual • Temporal • Parietal blinking, and pupils motor coordination – Memory – Visual field deficits – Difficulty with balance, – Nystagmus – Visual processing – Visual perceptual dizziness, nausea – Visual field deficits deficits / neglect – Speech / language – Movement deficits – Orientation 2 Physical Deficits with ABI Most common causes of TBI CDC 2006 Report • Musculoskeletal Complications • Heterotropic Ossification • Spasticity • Respiratory Complications • GI Complications • Swallowing Disorders • Bowel Incontinence • Genitourinary Problems • Dermatological Complications • Endocrine Complications • Autonomic Disturbances • Thrombophlebitis Commonly Overlooked Epidemiology Conditions in Blast Injury • TBI • Stroke (CVA) • Blast-related conditions (n=50) – 1.4 million/year in US – 700,000/year in US – 50,000 die each year • 500,000 first time CVA • Concussion (66%) • Chronic Infections (28%) – 235,000 hospitalized • 200,000 prior CVA • Soft-tissue Damage (62%) • Vision Changes (26%) – 1.1 million treated and – 160,000 die each year • PTSD (52%) • Lung injury (22%) released from the ER – In 2005, $57 billion dollars in direct & • Nerve damage (46%) • Tinnitus (20%) – 5.3 million (2% of US indirect costs • Acute or Chronic Pain • Vestibular problems population) need long- – The leading cause of (42%) (18%) term help with ADL – In 2000, $60 billion serious long-term • Hearing Loss (42%) • Undiscovered fragments disability in US (8%) dollars in direct & indirect costs –3rd leading cause of death in US Rehabilitation after ABI in A Team Approach Children • The rehabilitation team may include: – Physiatrists (Rehabilitation Physicians) • 25% of brain injuries in children younger than 2 years – Other physician specialists when needed are from physical abuse. • Outcomes after ABI are difficult to predict in children at – Neuro-psychiatrists/psychologists any age. – Optometrists • Studies have shown – contrary to the traditional plasticity – Pharmacists hypothesis youth is not necessarily an advantage in – Nursing staff outcome after ABI. • Young children are found to be very vulnerable to the – Physical & Occupational therapists effects of ABI. – Respiratory therapists • Prefrontal injury is strong indicator of negative outcome – Speech/language therapists in young children. – Cognitive therapists/Technology training • Consequences of ABI in young children often worsen over the years as child grows into the injury. – Recreational/Music therapists • Children can be overprotected, learn “helplessness,” and – Social workers absence of peers. – The patient’s family members – Orientation and Mobility 3 The Role of Optometry in TBI The Role of Optometry Rehabilitation • It is estimated that 90% of what we perceive is • Goals of the functional visual evaluation: through the visual system. – Diagnose and treat patients with ocular and visual deficits. • Vision problems may interfere with mobility, reading, writing, dressing, eating, locating – Counsel the patient and family as to the visual objects, grooming, social interaction, etc. sequelae resulting from the brain injury. – Counsel the patient, family, physicians, and • Vision problems may go undiagnosed if we rely therapists as to how to compensate for the on the patient to express complaints. patient’s visual deficits. Visual Deficits in Literature: Common Signs & Symptoms Blast Related Injuries • Signs: • Symptoms: • Palo Alta VA (n=50) – Eye turn (strabismus) – Double vision (diplopia) – 74% had visual complaints – Closing one eye – Blurred vision • Visual deficits reduce the ability to perform common tasks (reading, face recognition, ADL’s) – Head tilt or turn – Inability to sustain • These deficits are associated with increase hospital stay, risk – Bumping into objects attention on visual tasks of falls and hip fracture. – Abnormal posture – Dizziness – 38% had some type of visual deficit – Balance problems – Headaches • Blast injury more than doubled risk for visual impairment compared with other mechanisms of injury (MVA, GSW) – Poor depth perception –Eye strain – Difficulty reading – Nystagmus Goodrich, G., Kirby, J.K., Cockerham, G., Ingalla, S.P., & Lew, H.L. (2007). Visual function in patients of a polytrauma rehabilitation center: A descriptive study. Journal of Rehabilitation Research and Development, 44, 929-936. Visual Deficits in Literature: Blast Related Injuries Convergence • Blast related BV deficits (20-30%) Insufficiency Case – Accommodative Dysfunction – Convergence Dysfunction Study – Pursuit/Saccade Dysfunction – Nystagmus – Diplopia • Blasts associated with higher rates of damage to eye, orbit and/or cranial nerves. 4 Convergence Insufficiency OT Screening Continued Case Study • General appearance – Intact • Screening completed on 04/02/09 • Oculomotor – 26 year old Caucasian male, PTSD, Head injuries • Fixation, pursuits, saccades – Intact – Two deployments to Iraq (2004-2005 and 2006-2007) • NPC – 17-23 cm – Exposure to 3 blasts (2 open and 1 confined) • Avid reader who reports difficulty reading for long periods of time – LOC following 2 blasts – unsure of duration • Reports reading less than 10 minutes – Denies trauma to eyes – “I can’t read anymore. I get really frustrated. I – Reports hearing loss used to read a lot but now I can only read one – Reports migraine headaches page and then I am ready to throw the book down. I hate it.” – Reports light sensitivity and difficulty with reading • CISS Score – 44/60 • Reports using the computer less than 30 minutes • Dimmed computer monitor OT Screening Continued OD Examination • Reports light sensitivity indoors and outdoors • OD examination completed on 6/08/09 – Wears sunglasses and hats indoors and • NPC 30cm outdoors • Refraction OD +0.50-0.50 x 100, OS +0.25 – Benefited from CPF 527 with polarized 3 lens • Near Phoria 7∆ exophoria, Ranges Base out 10/-10 for outdoors (break and recovery). • 7∆ Base In Fixation Disparity with Wesson Card (FDWC) • Glare sensitivity especially when driving at night . • Difficulty with ADLs • Rx as refraction with base in prism 7∆ – Reading, computer use, outdoor activities • Brock string dispensed. – Completing college classes • Home Training System on Computer initiated. HTS Vision Therapy System Brock String • Purpose: To improve binocular • Purpose: To develop vision at near. better coordination between the eyes when – Convergence looking at objects located – Accommodation at different distances. – Smooth saccadic eye • Equipment: Six foot piece movement of string with three beads • Poor binocular vision can lead to that can be moved along fatigue and eye strain. the string. • Equipment: Computer software • Especially for patients • Appealing for use of computer, with very reduced NPC ease of use, tracking purposes. and discomfort with convergence. • Picture: www.homevisiontherapy.com • Picture: www.bernell.com 5 OT Intervention Tranaglyph • Session One: