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

Barriers Denial of any deficits – Anosagnosia Left Lower Quadranopsia – both eyes Left Neglect (Reading/Scanning) Memory issues Standing Balance poor Walking balance poor

Pen and Paper TasksTransfer of scanning skills to table top tasks.

Systematic scanning pattern Smooth scanning across a line in preparation for reading

NVT Static Scanning Sitting Standing

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

Transfer from walking frameto support cane.Ensuring balance, gait and Scanning skills are not Compromised.

Residential Scan – DrivewaysUnilateral Scanning to LEFT

Static and Dynamic Scanning for moving targets

SUPERMARKET TRAINING:Transferring scanning skills intoEveryday community settings.Preparation for independent living.

Transition -scanning to street crossing

Business Area

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)

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

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

Mr. P visual field report <5 degrees

Progression of Visual Scanning – Tunnel vision OU

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

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

ddd

Mr. S Income/Outcome Dynavision (D2) measure

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

• 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

• Audiology referral• Tinnitus Masker• Filters “white noise” in

environment

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

Recreation Needs

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

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

with postgeniculate damage of the visual system. Saccadic compensation training. Restor Neurol Neuroschince 1992; 4:245-54.10. Zihl J. In: Von Cramon D, Zihl J, eds. Neuropsychologische rehabilitation, Berlin: Springer-Verlag, 1988:105-31.11. Meienberg O, Zangemeister WH, Rosenberg M, Hoyt WF, Stark I., Saccadic eye movement strategies in patients with homonymous

hemianopsia. Ann Neurol 1981; 9: 537-4412. Gassel MM, Williams D. Visual function in patients with homonymous hemianopsia. Part II Ocularmotor mechanisms. Brain 1963: 86: 1-

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,

Thanks and Have Fun in Williamsburg!

Paul.koons@va.gov

Questions?