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Case Study: Angie

Case Study: Angie. Motor Vehicle Accident TBI: Damage to the frontal lobe, bi-temporal, bi-parietal and occipital craniotomy Left Homonymous Hemianopia Left Inattention Visuo-spatial deficits Visual processing deficits Left Hemiparesis Memory. Barriers.

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Case Study: Angie

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  1. Case Study: Angie • Motor Vehicle Accident TBI: • Damage to the frontal lobe, • bi-temporal, • bi-parietal and • occipital craniotomy • Left Homonymous Hemianopia • Left Inattention • Visuo-spatial deficits • Visual processing deficits • Left Hemiparesis • Memory

  2. Barriers • Denial of any deficits – Anosagnosia • Left Lower Quadranopsia – both eyes • Left Neglect (Reading/Scanning) • Memory issues • Standing Balance poor • Walking balance poor

  3. Transfer of scanning skills to table top tasks. Pen and Paper Tasks Systematic scanning pattern Smooth scanning across a line in preparation for reading

  4. NVTStatic Scanning Sitting Standing

  5. Transfer to Independent Walking and Scanning Step by step methodology in the transfer of scanning skills to mobility tasks in a graded fashion in a client’s local community.

  6. Transfer from walking frame to support cane. Ensuring balance, gait and Scanning skills are not Compromised.

  7. Residential Scan – DrivewaysUnilateral Scanning to LEFT

  8. Static and Dynamic Scanning for moving targets

  9. SUPERMARKET TRAINING: Transferring scanning skills into Everyday community settings. Preparation for independent living.

  10. Transition -scanning to street crossing

  11. Business Area

  12. Progression into Community – O&M • Visual Scanning strategies continue to Residential – Light Business area – street crossing • Increase multiple-stimuli in all environments • Decrease use of Cues and Prompts • At times, distract patient while on task by talking to them and observe if they stay “on task” • If consistent problems in dynamic environment (i.e.: proper scanning patterns), increase therapy sessions in static environment (i.e.: static visual scanning exercises)

  13. Timeline of Events - Angie • June 20, 2006 MVA accident admitted to hospital in ITALY • July 6, 2006 Transferred to Landstuhl, Germany Military Medical Center • July 7, 2006 Transferred to Bethesda NMC • July 22, 2006 Admitted Palo Alto VA Polytrauma Rehabilitation Center • September 22, 2006 Discharged from PRC; housed in community for continued outpatient rehabilitation services • October 24, 2006 Admitted to Brain Injury Rehabilitation Unit (BIRU), Post-Acute Transitional Rehab. • March 15, 2007 Discharged from the Air Force • May 23, 2007 Discharged from the Brain Injury Rehabilitation Unit per trainee request • June 27,2007 Purchased House in Texas near family and living independently, Attending University but having difficulty in remembering so much information Total VA Rehab. Timeline: • Acute Rehab – 4 months -- Post Acute Rehab – 5 months

  14. Types of Electronic devices for visual search/scanning activities

  15. Mr. P • IED blast in Iraq 10-20-2006 • Moderate TBI, LOC noted • Tunnel vision • underwent emergent right occipital and posterior fossa craniectomy

  16. Mr. P visual field report <5 degrees

  17. Progression of Visual Scanning – Tunnel vision OU

  18. Mr. S • 63 yr old vet with history of mild TBI sustained in Vietnam • Well-compensating for years • Recently (past 8 months to 1 year) has had increased vertiginous symptoms w/ dizziness • Increased difficulty with visual attention, specifically blurring of vision when concentrating on fixed objects • Difficulty with keeping head upright and visual scanning causes vet to lose balance • Plate in neck fusing vertebrae and increased pain from looking down so often

  19. Mr. S Vision Rehab • 12 sessions total • 1x per week • 1 hr lesson • Static scanning • White cane training to improve head up positioning • Lessons range from static to dynamic • Roller tip and bandu basher cane tips • Rural area training

  20. ddd

  21. Mr. S Income/Outcome Dynavision (D2) measure

  22. Meet Doug • 45 year old Army Ranger • TBI exposure • Temporal/Frontal Lobe atrophy • Motor apraxia (neck and left hand) • Visual Field constriction OU • Sees Pictures that persist: -Palinopsia ? • Slow visual processing • Auditory: Tinnitus • PTSD • MRI findings: microvascular disease, temporal, frontal lobe atrophy Title

  23. Major Visual complaint: Patient verbalizes • Not able to see motion (visual processing) • Sees pictures that persist, some frames empty • Tunnel vision • Extreme Photosensitivity • Blurred vision • Vision Testing: • No prior ocular disorders • 20/20 OU Distance • 20/20 OU Near (with +1.50 Readers OU) • Confrontation Visual Fields difficult to assess with motor apraxia • Fixation: 3 seconds before tics • Midline shift testing – wnl • Unable to determine: • EOM, NPC, Sacc, Pursuits, stereo

  24. Audiology referral • Tinnitus Masker • Filters “white noise” in environment

  25. Orientation & Mobility Goals • Dual Cane travel • Hallway travel with crowds • Independent residential travel • Improve response time • Improve auditory awareness • Improve auditory localization • Establish rest break/coping with crowds/excess noise • Visual Scanning/Maintain Eye level • Differentiating auditory stimulus vs. visual images • I.e.: hearing vs. seeing car first

  26. Recreation Needs

  27. VA On-line Resources • www.tbiguide.com • Nora website: www.nora.com • http://www1.va.gov/netsix-braininjury/ • CBIS (Certified Brain Injury Specialist) • www.Bernell.com • National Wheelchair Olympics in Richmond June 25-30th !! • HTS Home Therapy System • Neurovision Technologies • Dynavision D2 • Wayne Engineering Products

  28. References • Kerkhoff, G. “Neurovisual rehabilitation: recent developments and future directions.” J. Neurol. Neurosurg. Psychiatry 2000;68:691-706. • Verlander, D. et al. “Assessment of clients with visual spatial disorders: a pilot study” Visual Impairment Research, 2000, Vol 2,No 3, pp 129-142. • Zihl, J. “Ocular scanning performance in subjects with homonymous visual field disorders”, Visual Impairment Research, 1999, Vol.1, No.1, pp 23-31. • Parton, A. “Hemispatial neglect” J. Neurol. Neurosurg. Psychiatry 2004;75;13-21. • Goodrich GL, Kirby J, Cockerham G, Ingalla SP, Lew HL. Visual Function in Patients of a Polytrauma Rehabilitation Center: A Descriptive Study. Journal of Rehabilitation Research & Development. in press. • Taber KH, Warden DL, Hurley RA. Blast-Related Traumatic Brain Injury: What Is Known? J Neuropsychiatry Clin Neurosci. 2006;18(2):141-5. • TBI Survival Guide – Dr. Glen Johnson -- www.tbiguide.com • NeuroVision Technologies South Australia -- www.nvtsystems.com • Kerkhoff G, MunBinger, U, haaf E, Eberle-Strauss G, Stogerer E. Rehabilitation of homonymous hemianopsia scotomata in patients with postgeniculate damage of the visual system. Saccadic compensation training. Restor Neurol Neuroschince 1992; 4:245-54. • Zihl J. In: Von Cramon D, Zihl J, eds. Neuropsychologische rehabilitation, Berlin: Springer-Verlag, 1988:105-31. • Meienberg O, Zangemeister WH, Rosenberg M, Hoyt WF, Stark I., Saccadic eye movement strategies in patients with homonymous hemianopsia. Ann Neurol 1981; 9: 537-44 • Gassel MM, Williams D. Visual function in patients with homonymous hemianopsia. Part II Ocularmotor mechanisms. Brain 1963: 86: 1-36. • Ishiai S, Furukawa T, Tsukagoshi H. Eye fixation patterns in homonymous hemianopsia and unilateral spatial neglect. Neuropsychologia 1987; 25:675-79 • Zihl, J. Visual scanning behaviour in patients with homonymous hemianopia. Neuropsychol 1995; 33: 287-303 • Chedru F, Leblanc M, Lhermitte F. Visual searching in normal and brain damaged subjects. Cortex 1973;9: 94-111. • Poppelreuter W. Die Storungen der Niederen und Horeren Schleistungen durch Verletzungen des Okzipitalhirns. 1917. • Zangemeister WH, Meienberg O, Stark L, Hoyt WF. Eye head coordination in homonymous hemianopia. J Neurol 1982; 226: 243-54 • Zihl, J. Eye movement patterns in hemianopic dyslexia. Brain 1995; 118: 891-912. • Dynavision D2, Neurovision Technology Systems, Wayne Saccadic Fixator, Hart Chart, Home Therapy System, (HTS), Parquetry,

  29. Thanks and Have Fun in Williamsburg! Paul.koons@va.gov Questions?

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