Posts Tagged VISION
[Abstract] Review of rehabilitation and habilitation strategies for children and young people with homonymous visual field loss caused by cerebral vision impairment
Partial and homonymous visual field loss (HVFL) is a common consequence of post-chiasmatic injury to the primary visual pathway or injury to the primary visual cortex. Different approaches to rehabilitation have been reported for older adults with HVFL and there is evidence to support the use of compensatory training over other proposed therapies. We reviewed the literature to investigate the current state of the art of rehabilitation and habilitation strategies for children and young people with HVFL, and whether there is enough evidence to support the use of these strategies in the paediatric population. We have provided an overview of the existing literature on children and young people with HVFL, a brief overview of rehabilitation strategies for adults with HVFL, and evidence on whether these different interventions have been applied with children and young people effectively. We found that there have been very few studies to investigate these strategies with children and young people, and the quality of evidence is currently low. New research is required to evaluate which strategies are effective for children and young people with HVFL and whether new strategies need to be developed.
After having a stroke, many survivors are eager to start driving again. Driving offers independence and the ability to go where you want to go on your own schedule, so it is no surprise that survivors want to get back behind the wheel rather than rely on someone else for their transportation needs.
Unfortunately, having a stroke can have lasting effects that make driving more difficult. A survivor might not be aware of all of the effects of their stroke and could misjudge their ability to drive safely. Driving against a doctor’s orders after a stroke is not only dangerous, it may even be illegal. Many stroke survivors successfully regain their ability to safely drive after a stroke, but it is important that they do not attempt to drive until they are cleared by their healthcare provider.
How Stroke Affects the Ability to Drive
Having a stroke can affect an individual’s ability to drive in numerous ways, whether it be because of physical challenges, cognitive changes, or other challenges.
After a stroke, it’s common to experience weakness or paralysis on one side of the body, depending on which side of the brain the stroke occurred. More than half of all stroke survivors also experience post-stroke pain. Minor physical challenges may be overcome with adaptive driving equipment, but severe challenges like paralysis or contracture can seriously affect an individual’s ability to drive.
Driving requires a combination of cognitive skills, including memory, concentration, problem solving, judgement, multitasking, and the ability to make quick decisions. A stroke can cause cognitive changes that limit the ability to do many of those things.
As many as two-thirds of stroke victims experience vision impairments as a result of a stroke. This can include vision loss, blurred vision, and visual processing problems. Stroke survivors with vision problems should not drive until their problems are resolved and they have been cleared by a doctor.
Fatigue is a common physical condition after a stroke that affects between 40 and 70 percent of stroke survivors. Fatigue can arrive without warning, so it is dangerous to drive when suffering from post-stroke fatigue.
Warning Signs of Unsafe Driving
Stroke survivors are not always aware of how their stroke has limited their ability to drive. If they are choosing to drive after their stroke against their doctor’s advice, it is important for them and their loved ones to look out for warning signs that they might not be ready to start driving. Here are some of the common warning signs to look out for:
- Driving faster or slower than the posted speed or the wrong speed for the current driving conditions
- Consistently asking for instruction and help from passengers
- Ignoring posted signs or signals
- Making slow or poor decisions
- Becoming easily frustrated or confused
- Getting lost in familiar areas
- Being in an accident or having close calls
- Drifting into other lanes
If you or your loved one is showing any of these warning signs, immediately stop yourself or them from driving until your or their driving is tested.
Driving Again After a Stroke
Before a stroke survivor begins driving again, they should speak with their doctor or therapist to discuss whether or not it would be safe for them to continue driving. Many states require mandatory reporting by a physician to the DMV if their patient has impairments that may affect their driving after a stroke. Even if their doctor clears them to drive, they still will likely need to be evaluated by the DMV before they regain their driving privileges.
Driver rehabilitation specialists are available to help stroke survivors evaluate their driving ability from behind the wheel. There are also driver’s training programs that provide a driving evaluation, classroom instruction, and suggestions for modifying a car to the individual driver’s needs. For instance, an occupational therapist can provide a comprehensive in-clinic evaluation of a client’s current skills and deficits relative to driving.
From there a client could be sent for an in-vehicle assessment for further evaluation by a certified driver rehabilitation specialist (CDRS). They can assess driving skills in a controlled and safe environment. An in-vehicle driving test is the most thorough way to gauge a driver’s abilities. Each assessment takes about 1 hour and involves driving with a trained evaluator or driving in a computer simulator.
The “behind-the-wheel” evaluation will include testing for changes in key performance areas such as attention, memory, vision, reaction time, and coordination. After this assessment the CDRS can determine if the client is safe to drive, can not drive at all, or may drive with additional recommendations.
Often times clients may require certain modifications to their car in order to drive safely. In addition, some clients may benefit from on-going classroom training and simulation training in order to meet safety standards. These are all services that a driver rehabilitation specialist can provide. To help find these resources, The Association for Driver Rehabilitation Specialists has a directory of certified driver rehabilitation specialists, driver rehabilitation specialists, and mobility equipment dealers and manufacturers.
Get Back Behind the Wheel
Many stroke survivors successfully drive after a stroke; however, not all are able to. While reclaiming independence is important, staying safe is the greatest concern. It is important for stroke survivors to listen to their doctors and wait until they are fully ready before attempting to drive again. With some hard work and patience, getting back behind the wheel is possible.
All content provided on this blog is for informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. If you think you may have a medical emergency, call your doctor or 911 immediately. Reliance on any information provided by the Saebo website is solely at your own risk.
Vision and Rehabilitation After Brain Trauma (Part 1)
This is part one of a three-part article published to health.mil.
Vision Problems After Brain Injury
Visual problems following brain trauma are frequent and often complex. It is probably easiest to define the problems based upon how they affect incoming visual information (i.e., the afferent visual pathways) or the outflow of information to the visual organs (i.e., efferent visual pathways). Afferent defects include reduction in visual acuity, visual field, color vision, contrast sensitivity, comfort (usually as it relates to glare), and higher level visual processing, including recording of visual memory and comprehension of visual stimuli. Efferent defects include reduction of the ability to visually pursue a target, focus the lens inside the eye, train the two eyes onto a single target, maintain gaze once a visual target is obtained, and open and close the eyelids. In this three part series, we will describe 1) damage to the afferent visual pathways, 2) damage to the efferent visual pathways, and 3) the role of the neuro-ophthalmologist in visual restoration and rehabilitation.
The Afferent Visual Pathway and How Brain Injury Can Affect It
Light enters the eye through the cornea, the clear window of the eye. The cornea provides the majority of the focusing power of the eye, and is an extremely poor refractive surface, but with a healthy tear film it becomes nearly perfect. Brain injury often causes dry eye thereby reducing visual acuity. Furthermore, brain injury patients often lose an adequate blink response or develop lagophthalmos, the inability to completely close the eye. Dry, unprotected corneas are subject to scarring and infection.
Trauma to the brain often entails injury that can also shake or directly damage the eye along with the rest of the body. Patients suffering a blast injury can experience rapid elevation of pressure in the chest, which is then transmitted by the blood vessels to the retina, the neural tissue lining the inner wall of the eye. This is the tissue which converts light rays into the electrical impulses that are sent to the brain. The retinal blood vessels can rupture from the sudden increase in pressure and cause bleeding within the retina, a condition called Purtscher’s retinopathy. The free blood inside the eye can cause significant scarring and loss of vision.
Direct head trauma can also cause the eye to move too quickly and/or too far relative to the fixed structures in the eye socket. This can cause stretching or shearing of the optic nerve, the nerve that carries visual information to the brain. This traumatic optic neuropathy often can result in permanent visual impairment. Multiple direct head traumas also are a risk factor for problems within the eye itself, such as detachment of the retina from the back of the eye, or formation of a cataract, a clouding of the natural lens.
Trauma to the head invariably is associated with some degree of trauma to the neck, a risk factor for damage to the blood vessels of the neck. Injury to the wall of an artery can cause it to bulge (i.e., form an aneurysm) or separate from its inner lining (i.e., arterial dissection). Either situation can lead to abnormal blood flow to the visual pathways of the brain. Furthermore, either condition can cause the vessels to physically compress portions of the visual pathways, such as the nerves that control the eye muscles or the nerves that bring visual information to the brain. This could result in double vision or in reduction of visual acuity and visual field, respectively.
It has been demonstrated that the world we see is formed into a map upon our brain, specifically onto an area called the visual cortex. This map is organized such that the image of the world is inverted and reversed; the left side of our brain sees what is to the right of where we look and the right side of the brain sees light from the left of where we gaze. Furthermore, visual information emanating from above our visual point of interest is transmitted to the lower portion of the visual cortex while the upper portion of the visual cortex maps the visual world below the object of regard. It is for this reason that damage to the visual cortex causes loss of peripheral vision rather than simply loss of visual clarity.
While we do not know how visual memories are created or stored in our brains, it is known that brain injury slows the acquisition and processing of visual information and impairs the formation of visual memory. Recent research has suggested that these impairments may result from stretching or shearing of nerve fiber bundles after head injury. Sadly, higher level visual processing failure is often particularly difficult for a patient to express. Neuropsychologists have proven to be critically important for the diagnosis of these problems and for guidance in directing rehabilitation efforts.
From Stars and Stripes, March 2010, Health.mil.
- Vision and Rehabilitation After Brain Trauma (Part 2)
- Vision and Rehabilitation After Brain Trauma (Part 3)
- Vision Issues After Brain Injury: BrainLine Talks with Dr. Gregory Goodrich
- Vision Is Our Dominant Sense
- Introduction to Vision and Brain Injury
- What Does a Comprehensive Vision Exam Entail?
- Diagnosing Vision Problems After a Brain Injury
- Scanning Training in Neurological Vision Loss
[WEB SITE] Lost & Found: Caps, Sunglasses, and Earplugs – Strategies for Coping with Sensory Hypersensitivity – brainline.org
If it seems like your sense of touch, taste, smell, hearing, or vision is extra sensitive or heightened after your brain injury, it’s not your imagination. Sensory hypersensitivities are another major, yet not as obvious, contributor to fatigue and overload after brain injury. What we experience with our senses is essentially more information for our injured brains to try to process and organize. You can have difficulties processing sensory information just like any other information in your brain. Some examples of sensory hypersensitivities are:
- Sounds that you barely noticed before are alarming and startle you.
- It feels like you have megaphones in your ears.
- Background sounds and stimulating environments become overwhelming.
- Fluorescent and bright lights give you headaches.
- Clothing that was comfortable before feels irritating now.
- Large gatherings of people feel overwhelming.
Pain and fatigue can intensify sensory hypersensitivities, putting you in a hyper-sensitive or hyper-vigilant state. When you are in a hyper-sensitive or hyper-vigilant state, even subtle stimulants feel overwhelming. Especially sights and sounds that didn’t bother you before, may now trigger anxiety and the fight-or-flight response where your whole being feels threatened and out of control. You may shut down and not be able to do any more or you may feel compelled to escape from the situation. It can be very taxing, physically and mentally.
Stress management, movement and using all of your senses can help your brain organize and integrate the senses. This is similar to what children do. Consider how physically active children are as they grow and develop!
See Brain Recharging Breaks at the end of this chapter for some basic meditation techniques. Meanwhile, following are suggestions for coping with sensory hypersensitivities.
General Coping Suggestions
Limit exposure to avoid sensory overload.
- Avoid crowds and chaotic places where there are a lot of stimuli, like shopping malls.
- Do shopping and errands early in the week and early in the day, when stores are less crowded and quieter.
- Shop in smaller, quieter stores when possible.
- Eat out in restaurants when they are quieter, in between regular meal times.
- Hold conversations in a quiet place.
- Ask people to please speak one at a time. Explain that you’d really like to hear what everyone has to say but you can only hear one person at a time.
- Sleep during car trips.
- If you want to attend a function that you expect will be taxing, plan to stay only a short while. Take your cap, sunglasses and earplugs. Sit towards the back to minimize the sound and where you can easily exit to a quieter place or the car.
Monitor your pain, stress and fatigue levels.
Lights and sounds will bother you the most when you are stressed or fatigued. If you are feeling especially sensitive, use it as a cue that you need to take a break and use some relaxation techniques.
Try avoiding nicotine, caffeine and alcohol.
They may make the symptoms worse. If you have vertigo, try limiting your salt intake, which can cause fluid retention. Consider strengthening exercises for your neck with the guidance of a physical therapist.
When you are starting to feel stressed or anxious, try incorporating another sense.
- Put something in your mouth to chew or suck on. Strong flavors like peppermint or cinnamon are especially effective.
- Put on some soothing music.
- Apply some deep pressure. Give yourself a hug or press your palms firmly together or on the table. Squeeze the steering wheel if you are driving the car.
Experiment with activities and alternative therapies that involve your senses.
Listen to music, experiment with movement, dance, yoga, water, art, aromatherapy, etc.
Challenge your sensitivities.
Gradually increase your exposure and tolerance when using earplugs, sunglasses, etc.
Don’t eliminate the senses completely or you set yourself up for super-sensitivity.
Specific Coping Strategies
Sensitivities to sound
- Limit your exposure to noisy stores and loud situations like sporting events, the movie theatre and children’s school activities. Don’t participate or plan to stay for a limited amount of time. Sit on the outskirts so you can gracefully escape to a quieter place if needed.
- Use earplugs, try different kinds, and carry them with you.
- Use headphones for TV and music:
- For others, when you don’t want to hear it.
- For yourself, when you want to hear it better.
- Minimize distractions from snacking while doing things like working in groups or playing games. Use bowls for food instead of eating directly from noisy bags.
- Add some background sound – a fan, white noise machine, soothing music.
- Remove yourself from the situation and go to a quieter place as soon as possible, even the bathroom, when you feel overwhelmed or anxious. Then try:
- Closing your eyes
- Taking slow deep stomach breaths
- Putting an ice pack on your forehead and eyes
- Gradually expose yourself to different sounds and louder sounds to increase your tolerances.
Sensitivities to light
- Avoid bright light and fluorescent lights.
- Use sunglasses or a cap with a brim, even indoors.
- Try yellow tinted glasses if florescent lights are a problem.
- Try polarized sunglasses if driving glare is a problem.
- Try yellow tinted glasses if night driving is a problem.
- Make sure you are getting plenty of vitamin A (but not too much!).
- Eat orange colored fruits and vegetables like carrots, sweet potatoes, squash, and cantaloupe.
- Take a moment to just close your eyes for a few minutes when you are starting to feel stressed or anxious. This blocks out the visual stimuli.
Sensitivities to touch, taste, and smell
- Experiment! Cultivate an awareness of how things feel, taste and smell.
- Rub different textures on your arms, increasing the intensity to gradually decrease sensitivities.
- Add texture, contrasting temperatures and flavors to your food, like ice cream with crunchy nuts or chips with spicy taco sauce.
- Notice the textures.
- Pay attention to smells.
- How do different aromas make you feel?
If your sense of smell is altered, make sure to have functioning smoke and gas detectors in your home.
Doing cognitive work
- Plan to do cognitive work when your environment is quiet. Eliminate as many distractions and interruptions as possible.
- Screen out distractions by using earplugs or headphones, playing soothing music, or using a fan or white noise machine if you have sensitivities to sound.
- Turn down the volume on the phone and let the machine get it.
- Work in an uncluttered space or use a three sided table screen, to help screen out visual distractions.
- Give children headphones for the TV if you are having trouble screening it out.
- Do your “thinking” work while children are in school or asleep.
- Still having trouble concentrating? Try bringing in another sense.
- Put on some soothing nature or instrumental music, something without words at a low volume.
- Try chewing or sucking on something while you are working. Coffee stirrers can substitute for fingernails. Strong flavored or fizzy candies and gum can aid alertness.
- Try using some deep pressure by giving yourself a hug, pressing your palms strongly against each other or on the table.
- Try sitting on a large therapy ball while you work. A great strategy if you have trouble sitting still!
- Take a physical break, every 15 min. at first. Resist the urge to push through. I know it feels counter-intuitive but taking breaks will actually help you work longer! Gradually you will find you can increase the time between breaks.
- Use a timer – without a ticking sound!
- Pause and stretch, drink some water or make a cup of tea, walk around the house or the yard, rock in a chair, walk the dog, pat the cat.
Visual Processing Problems
Vision is an extremely important and complex source of sensory information. What you see with your eyes travels through your brain to the back area of your brain, where it is processed in the occipital lobe. There is a lot of territory between the eyes and the back of the brain where an injury can occur. The occipital lobe may be damaged directly from impact to the back of the head or it may be damaged indirectly from the ricochet of the brain inside the skull when the front of the brain is impacted. Damage to the occipital lobe frequently occurs in car accidents, falls and sports injuries. Even subtle visual problems following a brain injury can have a significant impact on cognition and functioning.
I wish I had known about visual problems and visual therapy when I had my car accident. I thought I was really going crazy! Fortunately for me, my issues improved with time but not without mishaps, like falling off a curb!
Some common problems after a brain injury related to vision include:
- Double vision
- Trouble tracking words on a page
- Impaired depth perception
- Hypersensitivities to light
- Difficulties remembering and recalling information that is seen
- Difficulties “filling in the gaps” or completing a picture based on seeing only some of the parts
- Trouble seeing objects to the side
- Low tolerances to changing light or clutter
- Impaired balance, bumping into objects
- Feeling overwhelmed when there is a lot of visual stimuli
If you notice problems in areas related to visual processing, please consult a visual therapist or a neuroopthalmologist, they can help!
- Don’t eliminate any sense completely or you set yourself up for a super-sensitivity.
- Gradually expose yourself to more light, sound, touch, smell, and taste.
- Be patient, in many cases your sensory hypersensitivities will decrease in time!
- Ask for physical therapy or occupational therapy with a therapist with a background in sensory integration for help with sensory sensitivities.
Some good news about sensory hypersensitivity is that it is also associated with a heightened sense of awareness and intuition. You may find that you feel more aware of your intuition and more creative since your brain injury. This is not uncommon. Enjoy!
Brain Recharging Breaks
If I had to choose one strategy that helped me the most after my brain injury, it would be learning to meditate. Meditation is especially helpful when you are experiencing sensory overload. It can help you calm yourself down from that hyper-sensitive state. It was also the only way I have found to give my brain a rest, to put it temporarily in a “cast”, like you would a broken limb. Often, after meditating for 15-20 minutes, the “logjam” in my brain clears up and I am somehow able to think again!
I recommend using some stress management or meditation techniques at least once a day. Plan it, schedule it in your planner, make it part of your daily routine. Meditation is not as mysterious as you might think. Try these basic steps:
- Get in a comfortable position on the bed, in a recliner or even in the car; uncross your arms and legs. Cover yourself with a blanket if you are cool.
- Close your eyes and do some slow deep breathing.
- Slowly inhale, expanding your stomach and counting to 7.
- Exhale gradually, contracting your stomach towards your spine, counting to 7.
Repeat. Repeat. Repeat.
When you are feeling more relaxed, as you continue your slow deep breathing, experiment with the following suggestions to increase the effectiveness of the experience.
Do a body scan checking for areas of pain or stress.
- Eyes closed, inhale deeply, picture your forehead and notice any stress or pain.
- Exhale and imagine the pain floating away with your exhale.
- Inhale, picture your eyebrows and notice any stress or pain. Exhale and release it, imagining the stress floating away.
- Repeat for your eyes, ears, jaw, throat, back of neck, shoulders … down to your toes. Breathe in relaxation, breathe out stress and pain.
Notice how you feel after you get to your toes!
- Visualize or imagine yourself in a warm, secure, relaxing, happy, peaceful place; floating on a cloud, floating in the water, or recalling a happy memory.
- Continue slow deep breathing.
- Focus on a picture or artwork that you like, noticing each detail.
- Continue slow deep breathing.
- Listen to music, any music that is soothing to you. Nature sounds or instrumental music is a good place to start experimenting.
- Continue slow deep breathing.
- Use aromatherapy – any scent that smells good to you. Favorite scents are often from childhood memories!
- Continue slow deep breathing.
Strive to let go of that never-ending tape of worries and “shoulds” that plays in your head. Focus on your senses – your breath, the music, a relaxing place, a comforting aroma. If thoughts drift in, gently push them away. It gets easier with practice, you’ll find what works best for you and you’ll be amazed at how much it helps you!
If you find these suggestions helpful and you want to learn more, check out classes in meditation, yoga, Tai Chi, and Qui Gong. Local medical facilities and high schools often offer classes at reasonable rates.
There are television programs that demonstrate different practices as well as a variety of DVDs you can rent from your local library to get an idea of which discipline suits you best.
Excerpted from Lost & Found: A Survivor’s Guide for Reconstructing Life After a Brain Injury by Barbara J. Webster. © 20ll by Lash & Associates Publishing/Training Inc. Used with permission. Click here for more information about the book.
- Vision Issues After Brain Injury: BrainLine Talks with Dr. Gregory Goodrich
- Vision Is Our Dominant Sense
- Vision and Rehabilitation After Brain Trauma (Part 1)
- Diagnosing Vision Problems After a Brain Injury
- Eating Issues After TBI
- Anosmia or Loss of Smell from Brain Injury
- The Tale of Two Smell Tests Post-Brain Injury
- Tinnitus and Brain Injury
- Hearing Loss After TBI
Selfies are all the rage these days. Using this popular technique of taking photos, Mastercard is trialing a new method of payment that may be helpful to people with disabilities. The company’s new mobile app, called “Identity Check Mobile” (and popularly known as Selfie Pay) allows shoppers to pay for their purchases online by taking a selfie.
This is how it works: The app, when first downloaded, takes a photo of the user, and stores a digitized photo of their face on Mastercard’s servers. When that user is shopping online on their computer, and is ready to pay, they get a notification on their phone to verify the purchase amount. Once they verify it (by simply tapping on the amount), the next screen asks them to take a selfie. The selfie is then matched with the digitized photo of that person’s face, and if there is a match, the purchase is approved. The app also asks the person to blink to ensure that a human is actually taking the selfie, and someone is not just holding a photo of the person in front of the phone camera.
This can be beneficial for people with not very good motor skills, amputees, people with vision impairment or anyone who would want to speed up the checkout process by not typing on the keyboard.
This app is already available in several countries in Europe, and Mastercard says it should be available across the globe starting sometime next year.
[ARTICLE] A Randomised Controlled Trial of Treatment for Post-Stroke Homonymous Hemianopia: Screening and Recruitment – Full Text
Virtual reality is a new technology that simulates a three-dimensional virtual world on a computer and enables the generation of visual, audio, and haptic feedback for the full immersion of users. Users can interact with and observe objects in three-dimensional visual space without limitation. At present, virtual reality training has been widely used in rehabilitation therapy for balance dysfunction. This paper summarizes related articles and other articles suggesting that virtual reality training can improve balance dysfunction in patients after neurological diseases. When patients perform virtual reality training, the prefrontal, parietal cortical areas and other motor cortical networks are activated. These activations may be involved in the reconstruction of neurons in the cerebral cortex. Growing evidence from clinical studies reveals that virtual reality training improves the neurological function of patients with spinal cord injury, cerebral palsy and other neurological impairments. These findings suggest that virtual reality training can activate the cerebral cortex and improve the spatial orientation capacity of patients, thus facilitating the cortex to control balance and increase motion function.
Efficacy and feasibility of home-based training of individuals with homonymous visual field defects.
…Findings suggest that home-based compensatory training is an inexpensive accessible rehabilitation option for individuals with HVFDs, which can result in objective benefits in searching and reading, as well as improving quality of life…