bo3 302 pryor - rehab summit€¦ · 18 references and photos tong j, maruta j, heaton k j, et...

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Session 302: Neuroplasticity Techniques for Vision ChallengesKaren Pryor PhD, PT, DPT

Leading the Way in Continuing Education and Professional Development. www.Vyne.com

VisionWhat you see, hear, feel and do is how you learn - affects motor skills

It is time to change how we look at vision

Don’t live in the past lane - Sam Horn

Advanced imaging and functional scans show us connections

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Copyright Karen Pryor PhD, PT, DPT

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Don’t Gamble on Vision

A whole new way of looking at vision

“Wait and See”Is not for me

14 million Americans suffer from visual impairment - some are your current patients - undiagnosed - not primary Dx

Adults - Age related macular degeneration, glaucoma, cataract and optic nerve atrophy, concussions, TBI, MVA, falls

Children - Retinopathy of prematurity, deficit in the visual centers of the brain, structural ocular abnormalities (cataract and retinal abnormalities, concussions, traumatic brain injuries, stroke https://nei.nih.gov/strategicplanning/np_low


Eye Chart“Normal” is more than being able to see the letters

Typical

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Primary Sense of Vision

Case Study

Born premature

Calcium on brain

MD, Nursing and LCSW talked with Mother

Stated the baby would not be functionally independent and would require total care

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Functional vision

Is how nervous system uses vision Incoming: Sensory experience Integration: Learning/processing, for Motor skills: Initial input and feedbackFeedback loops: Protect and autocorrect

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What Does Nystagmus Look Like Loss of Visual Security

Read this while you move your eyes left and right

Does color make a difference in being able to read?

Yellow Red

Blue Green


Nystagmus

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Nystagmus

Karen Pryor PhD, PT, DPT technique part of the COMPASS Program

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Nystagmus

Vision, vestibular and vibration

http://www.edoctoronline.com/medical-atlas.asp?c=4&id=21932

Vibratory Pathway


You only see the symptoms

Color Blindness or Loss of Color Discrimination

Depth perception

Near - Far

Dependence on light and shadows


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Eye Misalignment

Depth perception

Eye teaming

Reading

Sports

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TorticollisTorticollis or vision impairment?

Neurologic impairments?

Early treatment is optimal for resolution of cervical active range of motion and visual landscape

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Cortical Vision Impairment

Before treatment After treatment

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Neuroplasticity

What ever fires togetherWires together - Hebb

Vision to hearing

Hearing to visionDi George’s Syndrome

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Brain WorkCentral nervous system will learn new pathways

Understanding the principles behind function engages patient compliance with home programs

Learning is slow initially then becomes a faster route with repeated and novel activities

Practice is necessary - brain remembers what ever it does the most

PT Phone home program

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Vision Combines with Sound and Balance

Occipital Lobe is next door to Temporal Lobe

Vision combined with sound

Vision stimulation combined with semicircular canals

Networks are essential to learning

Available for detours

What ever fires together wires togetherHebb principle


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Treat Using What is Next Door

• Vision is 3-D is next door to:

• Hearing 3-D

• Balance 3-D

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Semicircular Canals

• Right angles

• Yes

• No

• I Don’t Know


• How does your brain figure out unusual information? Focus - Gaze

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Visual Development in the Fetus

Developing nervous system - brainstem, midbrain, cortex

Post injury -return to how they developed

Brainstem mechanisms responsible for saccadic eye movements

Cortical mechanisms responsible for control of gaze. (novel and memory)

Exercises can guide the axonal out growth - smell

Guide synapse formation and memory pathways using exercises


Start at the Top Cranial Nerves Affect Eyes

• Cranial Nerve 1 - Olfactory

• Part of the verification triad of eating

• Look - smell - taste

• 3D objects -Touch - touch - taste

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Cranial Nerves and Vision• Cranial Nerve II

• Optic nerve

• Exits the eye through an area in the back of the eye - optic disc which goes to the brainstem

• Impulses then travel to the brain

• Injury before optic chiasm - one eye blind

• After the optic chiasm - will have visual loss in 1/2 or 1/4 visual field for that eye

Wikipedia


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Cranial Nerve III

• Occulomotor nerve performance

• Stimulates ocular muscles - Pupil may be larger than normal

• Eyelid drooping

• Eye ball will present slightly downwards and abducted

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Cranial Nerve IV

• Trochlear Nerve

• Stimulates superior oblique muscle

• Damage

• During convergence will be unable to move the eye inferiorly

• Looking downstairs = double vision

• Head injuries and concussions


Cranial Nerve V

• Trigeminal nerve - brainstem

• 3 branches = V1, V2, V3

• V1 is opthalmic branch gives sensation to the eye, eyelid and lacrimal gland

en.wikipedia.orgCopyright Karen Pryor PhD, PT, DPT

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Cranial Nerve VI

• Abducens nerve

• stimulates one eye muscle

• Lateral rectus

• Damage - unable to move eye lateral

• May be damaged by intracranial pressure - TBI, CVA, hydrocephalus

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Cranial Nerve VII

• Facial nerve

• Closes you eyelid

• Patient may use eye drops to continue to moisturize the eye


Central Nervous System• Is a living system - You never step in the

same nervous system twice - KP

• Test and evaluate MRI, Pet Scan, EEG

• Document what is affected in the nervous system

• Realize how it will affect movements, function and learning

• Determine what is working and how treatments can rewire function for patient

• Treat the primary site and symptoms are easier to treat


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The Nervous System is Living and Constantly

ChangingYou never step in the same nervous system twice

Experience changes perception, interpretation and reaction

If an individual has a visual challenge may have auditory difficulties as well

Video documentation is essential and surpasses verbal explanation

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Central Nervous System Abnormalities

Cerebral vascular accident

Concussion

Traumatic Brain Injury

Missing, surgical removal or underdeveloped lobes

Agenesis Corpus Callosum - eyes work independently

Neonatal abstinence syndrome - low sensory perception

Down syndrome, low tone demonstrated, slow response to visual stimulation

Low vision - relies on sensory feedback from face, hands and feet - splints cover sensory endings

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Posture and Vision

Head and neck position can be altered in an attempt to align visual picture of

environment

With accommodative side bending it restricts of rotation

Rotation is primary and necessary for balance, acceleration and deceleration of

motion

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Vagus Stimulation• 10th cranial nerve

• Interfaces with parasympathetic nervous system, is also sympathetic

• heart, lungs, digestive tract

• What happens in Vagus does not stay in vagus.

• Wandering nerve - smooth muscle -vagal tone, organ systems

• Calm, cool, concentrate

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Autonomic Nervous System

CalmCool

Collected

Optimal learning environment


Neuroplasticity Basis

Vision and memory constantly change

Voluntary striated muscles under cortical control

Low or high tone in extraocular muscles - Neuroplasticity therapy can treat tone

Cortical mechanisms responsible for control of gaze. (novel and memory)

Exercises can alter connectivity to the developing visual system

Guide synapse formation and memory pathways

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Eye movements and visual processing

Eye movements are the first action to happen to strengthen or inhibit primitive reflexes

Eye movement is the first rotation

Eyes lead the head on motor skills

Central nervous system injuries may affect aspects of vision

Vision assist with initiation of movement, confirmation of position in space and maintenance of balance

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Integration of primitive reflexes

Use of extra ocular muscles can assist in changing the obligatory power of primitive reflex patterns.

The active movements of the eyes and body will then be able to move through positions functionally.


Primitive Reflexes and Visual Influence

Let’s see how we can take away the power

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Tone Regulation

• Reticular formation

• Brainstem

• Vision

• Vestibular system

https://www.yesware.com/blog/neuroscientists-can-teach-brain-brain-process-selling/

https://bhavanajagat.com/2010/05/10/i-am-consciousness-therefore-i-am/

Tone vs Strength

Strength - musclesTreatment - exercisesDirectional motionsRepetitionsFocus - near - farPlay longer

Tone - central nervous systemTreatment - Neuroplasticity exercises

Combine lobe functionsWhat ever fires together wires together - Hebb principle

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Visual Abnormalities

What happens when the eyes are not functioning together?

What will their world look like?

Cover one eye

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Brain imagingVisual TestingVisual perceptionAxonal guidance

Increased understanding of visual function

Factors that influence visual development

Regeneration of the visual system through Neuroplasticity techniques

If you use pathways they continue to develop

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Visual LearningHearing vs. Listening

Seeing vs. Learning

• 80-85% of the Central Nervous System is devoted to vision

• The visual system works in tandem with the vestibular system

• Guidance of visual fields, balance and hearing give reliable feedback loop information for motor skills and gait

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6 Muscles Move the EyeEach has a primary action and less efficient actions called secondary and tertiary actions

They are voluntary muscles

Eyes are also associated with the Autonomic Nervous System

They can be influenced by other senses smellsoundmovementscolorstouchsensory experiences pull vision toward a source

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Brain stem motor exercisesCreeping, crawling, rocking, rolling, swing, smell, taste

primitive reflex pattern alterationsCr

http://cmapspublic.ihmc.us/rid=1195444302070_1137470712_10904/Brainstem%20eye%20Movement%20(Pineda).cmap


http://www.cs.cmu.edu/~dccrow/uwaterloo/VESTIB.gif

Connectivity in the Central Nervous System

To

TToo

To be fully effectiveEvaluate and treat causes as well as symptoms

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Therapy may be first in the home

The sooner we begin vision therapy, the faster the patient progresses.

Early in life

Soon after damage

Vision connects to 80 - 85% of the central nervous system

Assists in progressing motor control and self care.

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Misalignment of Eyes

Striated muscles

High Tone

Low Tone

Influence on eye position

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Don’t gamble on vision

• Start therapy ASAP

• Avoid “wait and see”

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References and Photos

https://pixabay.com/en/photos/eyes/?&pagi=4

https://nei.nih.gov/strategicplanning/np_low

Tong J, Maruta J, Heaton K J, et al. Degradation of binocular coordination during sleep deprivation. Front Neurol (2016) 7:90. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4904152/ Retrieved

093017.

Becker‐Bense S, Buchholz H, Baier B, et al. Functional plasticity after unilateral vestibular midbrain infarction in human positron emission tomography. Plos.org (2016)

http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0165935 Retrieved 100117.

Rosenholtz R. Capabilities and limitations of peripheral vision. Annurev‐vision Vol. (2016) 2:437‐457. http://www.annualreviews.org/doi/full/10.1146/annurev‐vision‐082114‐035733Retrieved 100117.

Tailor VK, Schwarzkopf D S, Dahlmann‐Noor AH. Neuroplasticity and amblyopia: vision at the balance point. Curr Opin Neuro (2017) 30:Issue 1 p 74‐83. http://journals.lww.com/co‐

neurology/Abstract/2017/02000/Neuroplasticity_and_amblyopia___vision_at_the.12.aspxRetrieved 100117.

Doyle MP, Vision therapy in the modern behavioral optometry practice: The history of vision therapy and contemporary approaches to case selection, case management, and the delivery of treatment.

02/16. http://www.ovpjournal.org/uploads/2/3/8/9/23898265/doyle16.pdfRetrieved 100117.

en.wikipedia.org

https://www.yesware.com/blog/neuroscientists-can-teach-brain-brain-process-selling/

https://bhavanajagat.com/2010/05/10/i-am-consciousness-therefore-i-am/

https://nei.nih,gov/strategicplanning/np_strab

https://cnx.org/contents/[email protected]:fEI3C8Ot@10/Preface

https://commons.wikimedia.org/wiki/File:1107_The_Extrinsic_Eye_Muscles.jpg

http://cmapspublic.ihmc.us/rid=1195444302070_1137470712_10904/Brainstem%20eye%20Movement%20(Pineda).cmaphttps://www.ncbi.nlm.nih.gov/pubmed/16845314

https://www.ncbi.nlm.nih.gov/pubmed/4004019

bo3 302 pryor - rehab summit€¦ · 18 references and photos tong j, maruta j, heaton k j, et...

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