Oculomotor Function & Dysfunction
Binocular Coordination requires effective… |
Binocular Dysfunctions due to TBI may results in… |
- Smooth pursuits/tracking |
- Inadequate gaze stabilization and bifocal fusion |
- VOR |
- Poor eye-head dissociations |
- Saccades |
- Strabismus |
- Convergence |
- Diplopia with or without changes in gaze |
- Divergence |
- Suppression (brains response to diplopia) |
- Stereopsis/Spatial localization |
- Vergence Insufficiencies (usually convergence) |
- Focal and Ambient Visual Processing (Physiological diplopia ) |
- Accommodative Insufficiency (CN III) |
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- Visual fatigue due to poor oculomotor control |
Post-Concussion Syndrome
Signs or symptoms following a blow, hit, bump, jolt or any identified trauma to the head that persist >4 weeks include: |
Dizziness |
Slurred Speech |
Headaches |
Poor judgement & decision making |
Blurred Vision |
Memory problems |
Nausea |
Sleep disorders |
Vomiting |
Emotional instability |
- Nearly 1 in 5 persons with concussion end up having PCS
- Symptoms may last months or even years
- Controversial: pre-morbid characteristics can contribute to persistent PCS such as history of mental health problems and substance abuse
Patient presentations- skilled observation
Easily irritable or changes in personality -> “I feel crazy.” |
Rigid and stiff body movement |
Changes in speech: stammering, difficulty with cohesive thoughts |
Avoids stimuli: wears sunglasses, “I cannot go to the grocery store anymore.” |
Forgetful & unable to concentrate |
Avoidant behaviors (Self-isolates from others, decreased socialization; Stops participating in hobbies & extracurriculars) |
Differential Dx: 3 Takeaways
Needle in a haystack: Visual diagnoses often look like other diagnoses |
Be careful of jumping to conclusions. |
Certain diagnoses are more well-known by those who have influence (e.g., ADHD) |
What do people with oculomotor deficits feel?
I have a vision problem? |
Fatigued, stressed. |
Missing out on experiences. |
Stigma |
Self advocates, over explainers. |
Adapters – Not always beneficial long term. |
Why OT instead of “Vision Therapy?”
Occupational and physical therapy understand movement and function |
Advanced trainings or certifications can overlap with the same skill set as vision therapists |
OT collaborates with neuro-optometrists for guidance for vision-based therapy |
Insurance often does not cover Vision Therapy services!!!!!!!!!! |
Must perform adequate and efficient visual and vestibular screenings during the evaluation process |
Pediatric-based nature |
How to help manage symptoms within daily routine?
Many individuals with Mild TBI push themselves beyond a point of recovery, which often can leave them “helpless” for hours or even days. |
“Functional Activities Log”- Tracking specific activities that are perceived triggers for onset of symptoms; E.g. computer or screen-time, reading, scanning for grocery items, eating in a crowded restaurant, riding as a passenger in the car, etc.); Stigma, metal health concerns |
Goal: reduce onset of symptoms by participating in short spurts of activity over a longer period of time |
Functional Activity Log
1. Establish a baseline: Determine length of time an activity occurred resulting in onset of symptoms |
2. Establish the most effective strategy for reducing symptoms:E.g. meditation, laying down in a dark and quiet environment, covering eyes with palm of hands with slight application of pressure |
3. Establish a “Pacing” Plan: Terminating or pausing an activity prior to onset of symptoms; then resuming activity after symptoms subside |
- If onset of symptoms occur at 20 minutes, then pausing, terminating, and switching to a different task should happen prior to 20 minutes |
Every individual has different triggers, thresholds, and psychosocial supports that should be taken into consideration when developing an activities log and “pacing” plan.
Visual Perceptual Activities
Functional Activities |
Therapy Activities |
Dressing with or without AE |
Parquetry |
Applying make-up |
Puzzles |
Grocery shopping |
Tangrams |
Organizing spice rack and or pantry |
Mazes |
Sorting and organizing dishes from the dishwasher |
“Where’s Waldo?” |
Navigating Apps on phone or web browsers |
Graphing |
School and work-based tasks |
Line or design completion |
Visual Perceptual Strategies
Environment |
Person |
Occupation |
- Organization |
- Scanning strategies |
- Task analysis (grade up/down) |
- External cues (e.g., increase contrast) |
- Cognitive strategies |
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- Oculomotor strategies |
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Vision Therapy Activities
“White-board” Activities |
Eye-hand coordination, peripheral awareness |
Walking Trails |
Visual tracking, spatial and peripheral awareness, gaze stabilization, and balance |
Dowel Stick or Bunting using a Marsden Ball |
Peripheral awareness, eye-hand coordination, and stereopsis or depth perception |
Vectograms |
Convergence and divergence |
Red/Green Activities |
Reduce suppression of one eye while working both eyes simultaneously |
Dynavision
Objective measurement for reaction time and can be used daily |
Applied specifically for individuals returning to driving following TBI and stroke |
Visual speed of processing and reaction time do not solely determine drive readiness |
Contraindications: history of seizure-like activity |
Functional Therapeutic Activities
Activities may be done in clinic or given as therapeutic home programs: |
- Speed Typing Tests (several resources online) |
- Structured Internet Searches (i.e. locating a current event article, read it, and write or type a brief summary) |
- Car Scans (i.e. locating street signs, speed limit, etc. with or without moving head) |
- Reading a bedtime story to your kids |
- Scanning and clipping grocery store coupons |
- Grocery shopping (i.e. establish a grocery list of 5 items and increase by 2 items each trip) |
- Send email to therapist every Friday of new activities to add or replace on “functional activity log” for the next week |
Where OT splits from Vision Therapy!
Electronic Vision Therapy
Pros |
Cons |
Advanced vision therapy option for higher level goals (driving) |
Fatiguing |
Great for individuals who like objective measures and goals |
Photosensitivity |
Gamers like it |
Screen sensitivity |
Can provide experiences pen and paper can’t (dynamic reader;Tic-tac-toe-tack) |
May be challenging for more severe TBI |
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Seizure contraindications |
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