vision and sensory integration - oregon health & science ... · an mtbi patient can get...

Vision and Sensory

IntegrationKYLA LARAWAY MS, OTD, OTR/L

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?


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.


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


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


Difficulty

Reading

Playing sports (hitting/avoiding moving targets)

Convergence/Divergence


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


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)


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


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


Difficulty with objects moving in background or periphery

Driving, walking, biking…..life

Contrast Sensitivity


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.


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


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)


Can increase light sensitivity

Can cause blurry vision

Can increase fatigue, headache, eye strain

Diplopia/ Cover-Uncover


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


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


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


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


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


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


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

Whew! We made it to the end!

Thanks for joining me.

[email protected]

vision and sensory integration - oregon health & science ... · an mtbi patient can get...

Documents