vision and sensory integration - oregon health & science ... · an mtbi patient can get...
Post on 07-Jun-2018
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Rules to Live By
An mTBI patient can get “stirred up” with the OT evaluation.
Give them permission to rest and let them know they will be
provoked by the evaluation.
If you need to rest more than 1-2 minutes between tests, know that it
is ok to not fully finish the eval.
You want to decipher what is going on…but you don’t want to
wreck the patient for 1-2 days.
Symptoms to Watch For
Blinking more rapidly
Eye watering/strain
Headache
Nausea
Dizziness
Confusion/ fogginess
1 eye not tracking with the other eye (this is more objective on your
part vs. subjective by the patient)
Increased fatigue, sleepiness
Occupational Therapy Evaluation
History
Mechanism of injury and details associated (i.e. LOC, other injuries
sustained)
Occupational Profile
Roles, habits, routines
Stressors and areas of concern
Visual Function Evaluation/ VOMS
Client Centered Goals
Adolescent Adult Sensory Profile
Visual History
Last date of eye doctor appointment
Should be w/in a year, longer should be encouraged to see their eye
doctor
Prior visual history
Glasses/contacts
Near or far? Progressive lenses ?
Previous injuries to the eyes?
Retinal? Corneal?
Previous visual issues
“lazy eye”/Strabismus as a child?
Patient subjective functional complaints
General Appearance
Lights on, glasses off
Head position
Turned or tilted
Eye position
Are the whites of the eyes symmetrical both on the medial and lateral
borders?
Eyelid function
Open wide and close tight shut
Pupil symmetry
Are they symmetrical or not?
Functional Implications
Head turn or tilt:
can imply a self-modification for “un-yoked” eyes, double vision
Asymmetrical whites of the eyes:
indicates an “un-yoking” with potential for binocular suppression,
double vision, convergence insufficiency
Eye lid dysfunction:
Can implicate other neurological impairment
Facial muscle involvement
Corneal Reflection
This is one of the objective ways to assess if a client might be having
some diplopia
Shine from dead center up from under the nose and look closely for exactly matching reflections from penlight in eyes
Look for any difference, even subtle
Is one inward? Outward? Shifted slightly up or down as compared to the
other?
Functional Implications
Any asymmetry in the corneal reflection indicates both eyes not
sitting in the exact same position, “un-yoked”
A significant difference, usually indicates true diplopia (double vision)
A slight difference, usually indicates they won’t see “double” but
likely blurred or “smeared” vision
Pupillary Reactions
Lights dimmed, glasses off
At rest
Pupillary size at rest: dilated, constricted, normal (4-5mm)
With light stimulation
Quick stimulation
Sustained stimulation
The pupil should react to light by constricting, there is a normal give (1mm) as
the brain assesses if the iris can relax, then should constrict again. This is
normal hippus
If the pupil dilates and fluctuates greater than 1mm and pulsates, this is
abnormal hippus.
Functional Implications
Abnormal hippus will cause greater light sensitivity
They will be more sensitive to bright, glare, shadows, contrast, etc.
This condition primarily need adaptive intervention
Can recover over time with general recovery, but not always
Vestibular Ocular-Motor Screening
(VOMS)
Smooth Pursuits
Saccades
Horizontal
Vertical
Convergence/ Divergence
Vestibular-Ocular Reflex (VOR)
Horizontal
Vertical
Visual Motion Sensitivity
Visual Tracking/ Smooth Pursuits
Lights on, glasses off
Tongue depressor w/colored dot or A
Hold depressor 16-19” away from face (VOMS says 3’)
Client keeps head centered and moves only the eyes
Move to your left, right, center, up, down, center, diagonal left high
to right low, center, diagonal left low to right high
Most mTBI folks have full ROM and rare to not reach all points
Watch for quality of motion:
Jumpy or jerky or nystagmus
Functional Implications
Jumpy or jerky tracking can greatly effect reading
Lose place in reading or on the line, skip a line
Increases difficulty with moving objects, environments with crowds
Saccades
Lights on, glasses on
2 single focus points (markers, fingertips, pencil/pen)
Horizontal (20x)
1.5’ from midline on R and L, centered to patient’s head, eye level
Instruct patient to move eyes as quickly from R to L
Vertical (20x)
1.5’ from midline above and beyond, centered to patient’s head
Instruct patient to move eyes as quickly from up to down
Eyes should be hitting target, accurately with 1-2 movements
Convergence/Divergence
Lights on, glasses on
Measuring tape, pencil w/14pt font A or playing card
Explain the test and have them tell you “what happens along the way”
Dizziness, “foggy” feeling, visual pain/strain, headache, blurry image, double image, anything
Try and do without blinking
Head stays centered
Move card in slowly and watch closely for symmetrical eye movement
Measure at each point the patient does any of the following, be sure to note nearest point of fusion (2 objects):
Blinks, moves back, reports headache/dizziness or any other symptoms, asymmetrical eye motion
Abnormal: >6cm from tip of nose
Functional Implications
Where the person can converge can effect how well they see a
variety of things:
Computer
Book
Sports objects
etc
Vestibular Ocular Motor Reflex (VOR)
Lights on, glasses on
Metronome @ 180bpm
Ability to stabilize vision as the head moves
Integrated during childhood
Horizontal
Ask patient to rotate head horizontally (nod “no”) while maintaining
focus on target
Vertical
Ask patient to rotate head vertically (nod “yes”) while maintaining focus
on target
Functional Implications
Difficulty reading and focusing while in movement
Walking, driving, getting out of bed, changing position
Visual Motion Sensitivity (VMS)
Lights on, glasses on, facing busy environment
Patient in standing, feet shoulder width apart
Metronome @ 50bpm, trunk rotates 5x each direction
Ask patient to outstretch arm and focus on thumb
“Imagine there is a pole that goes from your head down to your
hips, rotate as one unit.”
Abnormal if induces dizziness, nausea, headache, fogginess
Functional Implications
Difficulty with objects moving in background or periphery
Driving, walking, biking…..life
Contrast Sensitivity
Lights on, glasses on
Lea Numbers Contrast Sensitivity
Chart
Instruct patient they will see a series
of numbers that get fainter and
fainter. Just read them out loud
Test at all 3 distances
If they can read all 25/25 at 3meters,
this is beyond normal. “Cat-like” vision.
Functional Implications
Greater than normal contrast sensitivity increases input to the brain
that we aren’t conscious of:
Colors, brightness
Shadows, glares
Extraneous background visual stimuli
Increases fatigue, headache, strain, nausea
Pupillary Response to
Accommodation
Lights on, glasses on
Detailed object near and far (cards, clock)
Instruct client to focus on near target (i.e, the Q on card) and then
to the far target (12 on clock)
Have them go back and forth from near and far slowly (about 3-5
seconds per distance)
Observe pupillary action
Pupils should constrict as they look near and dilate as they look far
Watch for hippus (abnormal fluctuations of iris)
Functional Implications
Can increase light sensitivity
Can cause blurry vision
Can increase fatigue, headache, eye strain
Diplopia/ Cover-Uncover
Lights on, glasses on
Focus point (card, diagram), vision occluder
This test will help you assess ocular position and binocular function
Patient holds card about 19” from face
OT covers R eye 3x, then L eye 3x, then random back and forth
Watch for any ocular motion in the un-covered eye
Functional Implications
Movement that happens every time you cover, indicates they are
likely having double vision
Movement that happens only occasionally, and what seems to be randomly, is indicative of binocular suppression.
Eye Dominance
Lights on, glasses on
Detailed card (clock), pin hole card
Hand both cards to patient
Ask them to view the number 12 through the hole by putting the
hole up to their face.
Avoid telling them which eye
The eye they go directly to is their dominant eye
Functional Implications
As you learn more about their visual skills, if their dominant eye is
weaker or being suppressed, that increases the work of the brain to
be forced to use the non-dominant eye.
This can increase fatigue, irritability
Sensory Processing:
Frame of Reference
Sensory integration framework originally developed and tested by
Jean Ayres, OTR/L when working with children with learning and
movement disorders (1970s).
This set of theories is based on patterns of how an individual registers,
modulates, and interprets visual, auditory, olfactory, vestibular,
tactile, and gustatory stimulation.
Sensory Processing for a TBI
population
The approach can be either: Remediation of sensory processing deficits to improve
behavior, learning, praxis, or feeding issues
Environmental modification
“Sensory diet”: regular sensory input to ‘feed’ sensory processing needs
Compensatory strategies The basis for significant amount of pediatric OT intervention
and emerging trends in mental health and geriatric intervention.
Threshold Tips and Tricks:
Visual
Reduce glare
Tinted lenses
Colored transparencies
Brimmed hats
Minimize visual clutter
Threshold Tips and Tricks:
Auditory
Wear ear plugs, ear buds, noise cancelling ear phones
Choose environments or spots that minimize stimulation
Reinforce speech therapy recommendations for memory and
auditory processing
Threshold Tips and Tricks:
Activity Level
Reinforce education about pacing
Mini breaks
Use timers
Use calming tactile or auditory stimulation when over threshold or
alerting stimulation when below registration point
Shop at less busy times/places
Reinforce and problem solve physical therapy recommendations
about activity level
Threshold Tips and Tricks:
Taste and Smell
Utilize liquids which are calming
Hot tea
Decaf coffee
Use smells that are calming
Lavender
Essential oils
At the threshold is not the time to try the spicy Indian food
Registration Tips and Tricks:
Vision
Ensure good illumination
Larger print if available
Higher contrast
Remember: to reach registration the sensory input must be
slightly greater than normal.
Registration Tips & Tricks:
Auditory
Utilize music or sounds that is alerting, pleasing and “happy”
Have take notes to ensure recall later, it helps the brain pay
attention
Registration Tips & Tricks:
Activity Level
Work with PT to know what activity is “ok”
Often, static light weight lifting can help increase input to the
brain, without being too difficult.
Be mindful of obstacles: carpets, tables…as when they are
below registration they will trip, crash into things, etc.
Registration Tips and Tricks:
Taste and Smell
Utilize liquids which are alerting
Carbonated beverages
Minty
Gum
Smells that help “awaken”
All kinds…find what the patient likes and coach them when to use it.
Now is the time to try spicy foods
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