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Interventions for Visual PP Dysfunctions Cheat Sheet by

Interventions for Visual Perceptual Processing Dysfunctions

Oculomotor Function & Dysfun­ction

Binocular Coordi­nation requires effective…
Binocular Dysfun­ctions due to TBI may results in…
- Smooth pursui­ts/­tra­cking
- Inadequate gaze stabil­ization and bifocal fusion
- 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)
- 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:
Slurred Speech
Poor judgement & decision making
Blurred Vision
Memory problems
Sleep disorders
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.
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
Applying make-up
Grocery shopping
Organizing spice rack and or pantry
Sorting and organizing dishes from the dishwasher
“Where’s Waldo?”
Navigating Apps on phone or web browsers
School and work-based tasks
Line or design completion

Visual Perceptual Strategies

- Organi­zation
- Scanning strategies
- Task analysis (grade up/down)
- External cues (e.g., increase contrast)
- Cognitive strategies
- Oculomotor strategies

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
Conver­gence and divergence
Red/Green Activities
Reduce suppre­ssion of one eye while working both eyes simult­ane­ously


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

Advanced vision therapy option for higher level goals (driving)
Great for indivi­duals who like objective measures and goals
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
Seizure contra­ind­ica­tions


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