Case Study: Angie
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Motor Vehicle Accident TBI:
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Damage to the frontal lobe,
bi-temporal,
bi-parietal and
occipital craniotomy
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Left Homonymous Hemianopia
Left Inattention
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Visuo-spatial deficits
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Visual processing deficits
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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 Tasks
Transfer of scanning skills to table top tasks.
Systematic scanning pattern
Smooth scanning across a line in
preparation for reading
NVT Static Scanning
Sitting
Standing
Transfer to Independent
Walking and Scanning
Step by step methodology in the transfer of scanning skills to
mobility tasks in a graded fashion in a client’s local community.
Transfer from walking frame
to support cane.
Ensuring balance, gait and
Scanning skills are not
Compromised.
Residential Scan – Driveways
Unilateral Scanning to LEFT
Static and Dynamic
Scanning for moving targets
SUPERMARKET TRAINING:
Transferring scanning skills into
Everyday community settings.
Preparation for independent living.
Transition -scanning to street crossing
Business Area
Progression into Community – O&M
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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)
Timeline of Events - Angie
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June 20, 2006
July 6, 2006
MVA accident admitted to hospital in ITALY
Transferred to Landstuhl, Germany Military
Medical Center
Transferred to Bethesda NMC
Admitted Palo Alto VA Polytrauma
Rehabilitation Center
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July 7, 2006
July 22, 2006
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September 22, 2006
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October 24, 2006
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March 15, 2007
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May 23, 2007
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June 27,2007
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Total VA Rehab. Timeline:
Acute Rehab – 4 months -- Post Acute Rehab – 5 months
Discharged from PRC; housed in
community for continued outpatient
rehabilitation services
Admitted to Brain Injury Rehabilitation Unit
(BIRU), Post-Acute Transitional Rehab.
Discharged from the Air Force
Discharged from the Brain Injury
Rehabilitation Unit per trainee request
Purchased House in Texas near family and
living independently, Attending University but having
difficulty in remembering so much information
Types of Electronic devices for visual
search/scanning activities
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
Progression of Visual Scanning – Tunnel vision OU
Mr. S
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63 yr old vet with history of mild TBI
sustained in Vietnam
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Well-compensating for years
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Recently (past 8 months to 1 year) has
had increased vertiginous symptoms w/
dizziness
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Increased difficulty with visual attention,
specifically blurring of vision when
concentrating on fixed objects
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Difficulty with keeping head upright and
visual scanning causes vet to lose
balance
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Plate in neck fusing vertebrae and
increased pain from looking down so
often
Mr. S Vision Rehab
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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
ddd
Mr. S Income/Outcome Dynavision (D2)
measure
Meet Doug
Title
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45 year old Army Ranger
TBI exposure
Temporal/Frontal Lobe
atrophy
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Motor apraxia (neck and left
hand)
Visual Field constriction
OU
Sees Pictures that persist: Palinopsia ?
• Slow visual processing
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Auditory: Tinnitus
PTSD
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MRI findings:
microvascular disease,
temporal, frontal lobe
atrophy
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Major Visual complaint: Patient verbalizes
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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
Orientation & Mobility Goals
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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
Recreation Needs
VA On-line Resources
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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
References
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Kerkhoff, G. “Neurovisual rehabilitation: recent developments and future directions.” J. Neurol. Neurosurg. Psychiatry 2000;68:691-706.
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.
Zihl, J. “Ocular scanning performance in subjects with homonymous visual field disorders”, Visual Impairment Research, 1999, Vol.1, No.1, pp 23-31.
Parton, A. “Hemispatial neglect” J. Neurol. Neurosurg. Psychiatry 2004;75;13-21.
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.
Taber KH, Warden DL, Hurley RA. Blast-Related Traumatic Brain Injury: What Is Known? J Neuropsychiatry Clin Neurosci. 2006;18(2):141-5.
TBI Survival Guide – Dr. Glen Johnson -- www.tbiguide.com
NeuroVision Technologies South Australia -- www.nvtsystems.com
Kerkhoff G, MunBinger, U, haaf E, Eberle-Strauss G, Stogerer E. Rehabilitation of homonymous hemianopsia scotomata in patients with postgeniculate
damage of the visual system. Saccadic compensation training. Restor Neurol Neuroschince 1992; 4:245-54.
Zihl J. In: Von Cramon D, Zihl J, eds. Neuropsychologische rehabilitation, Berlin: Springer-Verlag, 1988:105-31.
Meienberg O, Zangemeister WH, Rosenberg M, Hoyt WF, Stark I., Saccadic eye movement strategies in patients with homonymous hemianopsia. Ann Neurol
1981; 9: 537-44
Gassel MM, Williams D. Visual function in patients with homonymous hemianopsia. Part II Ocularmotor mechanisms. Brain 1963: 86: 1-36.
Ishiai S, Furukawa T, Tsukagoshi H. Eye fixation patterns in homonymous hemianopsia and unilateral spatial neglect. Neuropsychologia 1987; 25:675-79
Zihl, J. Visual scanning behaviour in patients with homonymous hemianopia. Neuropsychol 1995; 33: 287-303
Chedru F, Leblanc M, Lhermitte F. Visual searching in normal and brain damaged subjects. Cortex 1973;9: 94-111.
Poppelreuter W. Die Storungen der Niederen und Horeren Schleistungen durch Verletzungen des Okzipitalhirns. 1917.
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Zangemeister WH, Meienberg O, Stark L, Hoyt WF. Eye head coordination in homonymous hemianopia. J Neurol 1982; 226: 243-54
Zihl, J. Eye movement patterns in hemianopic dyslexia. Brain 1995; 118: 891-912.
Dynavision D2, Neurovision Technology Systems, Wayne Saccadic Fixator, Hart Chart, Home Therapy System, (HTS), Parquetry,
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Thanks and Have Fun in Williamsburg!
Paul.koons@va.gov
Questions?