Strategies for Working with Clients with Vision Loss and Acquired Brain

InjuryRenee Man, CVRT/COMS

Alicia Golden, OTR/L

Neuroanatomy 101

Common TBI Effects: Physical-upper extremity

Deficit Possible affect on VRT work•Decreased sensitivity in fingers•Altered sensation in fingers•Decreased coordination•Decreased strength•Decreased hand eye coordination•Dysmetria•Stereognosia •Tremors•Hemi-paresis or paralysis

•Devices are cumbersome•Many devices are heavy (magnifiers)•Buttons on devices are often small and close together•Use of tactual input

Cognitive Processes

• Orientation-awareness of time, place, etc• Insight-ability to recognize impairments• Attention-ability to maintain focus over a

period of time• Memory-ability to recall information• Executive functioning-“CEO responsibilities”

Executive Functioning

• Initiation• Planning• Organization• Follow through• Time management• Problem solving• Self monitoring

Common TBI Cognitive Effects:Orientation

Deficit Possible Affect on VRT work•Inability to accurately identify person, place, time

•Difficult to find appropriate orientation device (i.e. watch, calendar systems, etc)

Common TBI Cognitive Effects:Insight

Deficit Possible Affect on VRT work•Inability to recognize deficits at all •Difficulty recognizing functional impact of deficits

•Can often look like denial or obstinence•Refusing to use adaptive equipment or techniques •Can take awhile to find activities that “hook” the client

Common TBI Cognitive Effects:Attention

Deficit Possible Affect on VRT work•Difficulty focusing on a task•Being easily distracted•Inability to stick with a task for a period of time

•Many VRT skills require lengthy training•Can’t remember what they can’t attend to

Common TBI Cognitive Effects:Memory

Deficit Possible Affect on VRT work•Difficulty recalling newly learned information•Sometimes difficulty recalling old memories•Unable to rely on previously learned skills

•Difficult to progress through training of skills or equipment quickly•Need increased time to learn new skills•Can’t use visual cues that are heavily relied on in brain injury rehab

Common TBI Cognitive Effects:Executive Functioning-Initiation

Deficit Possible Affect on VRT work•Difficulty starting tasks•Can look like decreased motivation or laziness

•Frustration with apparent “laziness” •Frequently running into road blocks in progress

Common TBI Cognitive Effects:Executive Function-Planning/Sequencing

Deficit Possible Affect on VRT work•Difficulty completing tasks in order•Encounter frequent roadblocks

•Again frequent roadblocks with progress•Often rely on teaching clients by doing

Deficit Possible Affect on VRT work•Difficulty with categorization•Secondary to memory impairments, clients end up with duplicates•Can’t recall organizational systems

•Organization that seems innate to us, doesn’t make sense to clients•VRTs rely on organizational systems for everything

Common TBI Cognitive Effects:Executive Functioning-Organization

Deficit Possible Affect on VRT work•Difficulty completing final step of task

•Difficulty with homework•Limited use of skills when you aren’t there

Common TBI Cognitive Effects:Executive Functioning-Follow Through

Deficit Possible Affect on VRT work•Unable to estimate time required to complete tasks•Can over/underestimate-impulsivity•Difficulty balancing a daily schedule and managing time within a day

•Difficulty accomplishing training VRT set out to do•Difficulty finding appropriate time management systems

Common TBI Cognitive Effects:Executive Functioning-Time Management

Deficit Possible Affect on VRT work•Difficulty identifying problems•Difficulty identifying root of problem•Difficulty identifying appropriate solutions to problems•Difficulty with flexible thinking associated with alternative solutions

•Teach clients strategies, but use their own problem solving to “make it their own”•Many times clients come up with their own solutions to functional problems

Common TBI Cognitive Effects:Executive Functioning-Problem Solving

Homonymous Hemianopsia• Field loss on the same side in both eyes– Inner half of one eye and outer half of the other– Damage to right side of brain causes vision loss on

left and vice versa– Can present as reduced acuity or complete lack of

vision and anywhere in between

Common TBI Visual Deficit:Homonymous Hemianopsia

Deficit Possible Affect on Neuro rehab •Bumping into things•Reporting that objects jump out at them•Tripping/falling•Knocking things over

•Difficultly in completing ADLs/IADLs thoroughly or accurately•Difficulty using visual cues for these tasks•Decreased safety with cooking tasks, etc•Difficulty navigating within unfamiliar locations

Visual Neglect

• Attentional deficit to one side of body• Differs from hemianopsia in that there is not

an actual loss of visual field

Common TBI deficit:Visual neglect

Deficit Possible Affect on Neuro rehab•Unable to attend to one side •Difficulty performing ADLs/IADLs

thoroughly•Difficulty locating required items for tasks•Difficulty navigating unfamiliar locations•May look like decreased social pragmatics, etc if not acknowledging people

Potential Interventions

• Computer based scanning training– Brain Train– Neuro Vision Technology Systems-standardized

assessment and training tool www.nvtsystems.com.au

• Gottlieb Visual Field Awareness System – Round prism that moves missing image 20

degrees closer to center

Other common deficits

• Dry eye– Due to slower blink rate or incomplete closure of

eye when blinking– Risk of corneal abrasions

• Double vision– May occur when eyes have trouble working

together – Dizziness often results from double vision limiting

ability to participate in therapies

Common TBI Vision Deficits:Dry Eye and Double Vision

Deficit/Symptoms Possible Affect on Neuro rehab•Dry eye•Corneal abrasions•Presence and treatment can limit time in therapy

•Inability to participate secondary to pain

•Dizziness•Difficulty tracking and scanning•Require training in patching or prisms•Fatigue

•Difficult to participate in functional tasks, especially standing or mobility based•Unable to tolerate dynamic therapy sessions (ie. community, group settings)

Case study History

• 49 y/o female with TBI secondary to fall with initial damage to bifrontal lobes and right parietal lobe secondary to hemorrhage

• PMHx: severe diabetes with renal transplant, diabetic retinopathy, and cataracts

• Prior to injury: living independently in own home, driving, working full time as a CPA, single parent caring for two young children (10 and 7)

Brain injury deficits

• Decreased working and short term memory• Insight, judgment and safety awareness• Attention• Problem solving• Left neglect-undiagnosed• UE tremors• Balance issues• Behavioral dysregulation

Long term goals

• Get out of wheelchair• Live independently• Return to driving• Return to work

Short term goal and interventions:“Get out of wheelchair”

• Worked with PT to regain strength and balance

• Modified living environment– Used high contrast tape around outside of door

frame– Installed grab bar on right hand side of wall across

from apartment door• Continue to recommend supervision with less

familiar and community locations

Short term goals and interventions:Independent living

• ADLs– Tried “morning routine” checklist– Modified environment and room setup, including

clothing organization and task lighting– Installed grab bars and high contrast tape on shower

• Cooking– Modified recipes (large font, task breakdown)– Color coded stove and microwave– Trained in use of adaptive equipment– Given new living environment, labeled cabinets

Modified Stove

Short term goals and interventions:Independent living

• Medication management– Strategies for opening bottles– Developed modified medication list– Relabeled medications with large simple labels– Attempted training in pillbox– Used auditory alarm for medication schedule

Modified Med Management

• Time management– Talking watch– Set up Google calendar with built in

reminders/alarms– Sync’d calendar with cell phone– Input all MD contact info into phone

Short term goals and interventions:Independent living

Short term goals and interventions:Return to driving

• Completed research around requirements for return to driving

• Wrote article for client newsletter• Set client up with The Ride (local paratransit)• Did training around The Ride– Developed large font script for calling in Ride– Trained in online based scheduling and account

balance– Problem solving training in case an issue arises

Short term goal and interventions:Return to work

• Computer training– Use of built in accessibility features (ie. zoom,

enlarging websites, text to voice, speech recognition)

• Training in hand held magnification• Training in use of visual markers and scanning

techniques for neglect

Case Study History

• 64 y/o female who sustained a brain injury related to ruptured posterior inferior cerebellar aneursym, with clipping

• No significant PMHx• Prior to injury: working full time + as physician

and medical executive, living independently with husband, has 2 grown children and 1 grandchild, physically active (hiking), enjoyed travelling

Resulting deficits

• Decreased sensitivity, strength, balance, coordination, tremors

• Field loss and acuity; however, difficult to quantify

• Dry eyes• Fatigue• Memory• Executive functioning

Long term goals

• “I want to see better”• Scanning• Cooking• Handwriting

Interventions: Scanning• Scanning with sequencing of shapes • Incorporating motivating items (pictures of grandson,

medical pictures, etc)• Progressed to sequence of random letters in large

block print• 1” block tiles with near vision• Scanning with meaningful activities (ie. trimming

flowers)• Vertical scanning: braiding, math problems, medical

words• Now incorporating more functional scanning tasks

Intervention: Cooking

• Added contrasting tape to cooking utensils• Used adapted cutting board and Y peeler to

peel potatoes for mashed potatoes• Progressed to muffins from mix and filling

muffin tins• Then to cookie dough with rolling pin• Then to “worms in dirt” for son’s birthday

Intervention: Handwriting

• Drawing straight lines with visual marker for right side of page, task lighting, 20/20 pen

• Angled paper on a binder• Able to write simple words (name, numbers)• Able to consistently sign greeting cards• Difficulty determining appropriate glasses

(distance vs. near)

IDEAS?