Vision Therapy

 

Vision Therapy can be effective in resolving a range of post-concussion symptoms stemming from vision problems. Specially trained optometrists can diagnose problems with eye-teaming, focusing, and visual tracking and professional vision therapy can "retrain the visual system to help eliminate the visual symptoms most commonly associated with post-concussion syndrome."


A high percentage of concussion patients develop vision problems

In a 2016 study of adolescent concussion patients, 69% were diagnosed with one or more vision problems. Research suggests that over 50% of adults with a concussion or post-concussion syndrome have visual problems that can cause headaches, eye strain, and double or blurred vision. A 2017 study of concussion patients who were referred for a vision exam found that 82% received a diagnosis of an oculomotor problem.

It makes sense that concussions would cause vision problems; there is a  widespread distribution of visual pathways through the brain, and more areas of the brain are used to process vision than any other system in the brain.

The vision problems that develop after a concussion are not visual acuity (20/20) problems, but rather eye teaming, focusing, and tracking which create difficulties with reading and with sports.

In this video produced by the U.S. Army, Lt. Col. Debra McNamara, Chief of Optometry at Wiesbaden Army Health Clinic, discusses a type of therapy being used to visually detect and treat vision disorders which are common with concussions and traumatic brain injuries.


Even mild concussions can cause these vision symptoms

 Visual Link to the Brain, from the Neuro-Optometric Rehabilitation Association

Visual Link to the Brain, from the Neuro-Optometric Rehabilitation Association

  • double vision

  • blurred vision

  • eye strain and fatigue

  • headaches that intensify with the use of the eyes

  • dizziness and nausea

  • difficulty tracking moving objects or loss of place when reading

  • light sensitivity

  • motion sensitivity


Some of the vision problems most common to concussion patients are also the kind that most people never know they have

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Convergence insufficiency (the eye's ability to converge together on a near object, such as a book or screen) is the most prevalent concussion-related visual problem and accommodative insufficiency is second. Most people with convergence insufficiency never know they have it because rather than seeing double, the brain may suppress information from one eye.

The symptoms of vision problems don't always appear to be vision problems, so the patient and the medical specialists may not spot the problem. Examples of symptoms that don't appear to be obviously vision-related are: 

  • headaches in forehead or temple

  • being overwhelmed in visually stimulating environments

  • school work or computer work takes hours longer than it should

  • problems with coordination (tripping/stumbling and poor eye-hand coordination)

  • becoming fatigued with reading.

Here is a comprehensive behavioral signs and symptoms of vision problems.


Vision problems in concussion patient are routinely missed; your optometrist, sports medicine doctor, neurologist, general practitionermay miss concussion-related vision problems

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When your optometrist checks your eyes and decides on a prescription for glasses, she is measuring for visual acuity. Visual acuity describes the sharpness of sight, such as seeing the small letters in an eye chart from across the room. Typical eye exams do not measure the vision problems seen with concussions. In one study in which vision dysfunction was found in a high percentage of concussion and TBI patients, the researchers commented that "visual acuity remained normal in most of these patients and was not a reliable predictor of visual outcome after brain injury."

To put this in perspective, two Concussion Alliance community members were screened by their family optometrist and were told their eyesight was fine. They also saw numerous specialists who had never suggested a comprehensive vision exam - including their sports medicine doctor, sports concussion specialist, neurologist, and neuropsychologist. Much later both patients were examined by an optometrist specializing in Vision Development and both had numerous, significant vision problems. 


It's highly recommended that all concussion patients be given a comprehensive vision exam

Multiple research papers strongly recommend that patients with concussions, post-concussion syndrome, or any type of brain injury should be given a comprehensive vision examination, specifically testing for convergence, eye movement, and accommodative function. These types of tests are not done by your family optometrist or a neurologist, but by an optometrist specializing in vision development or an optometrist trained in neuro-optometric rehabilitation. Some neuro-ophthalmologists and developmental ophthalmologists also do this type of diagnosis. The vision exam will include visual acuity at near, eye teaming skills, eye focusing skills, and eye movement skills.

A comprehensive vision exam as described above is not yet part of the international consensus on concussion management. The 2016/2017 International Consensus Statement On Concussion In Sport recommends that all athletes should have a clinical neurological assessment which includes oculomotor function. The oculomotor function assessment performed by a neurologist, however, is not the same as the comprehensive vision exam which tests for convergence, eye movement, and accommodative function, as well as other eye skills.

One of our founders was cleared for oculomotor function when clinically assessed by a neurologist. Later, after 22 months of constant headaches, he was given a comprehensive exam by an optometrist specializing in vision development and found to have numerous significant vision problems.

How to Access Vision Diagnosis and Therapy

Ask your doctor for a referral to a specialist, or you can self-refer to a specialist or vision therapy center. For optometrists specializing in diagnosing oculomotor problems common to concussions, we suggest using all the search tools below, as they have different databases.

Use the search tool above to find a practitioner with a Fellowship certified by the College of Optometrists in Vision Development (COVD). Ask if they have experience with concussions or brain injury - many do, but some specialize in other areas such as children's vision issues or autism. 

Use the search tool above to find a practitioner certified by the Neuro-Optometric Rehabilitation Association (NORA). All NORA optometrists deal with concussions and acquired brain injury.

The practitioner search tool above was created by a group of optometrists throughout the United States who are certified Fellows of the College of Optometrists in Vision Development. 


Several types of specialists can diagnose ocular-motor (vision) dysfunction

  • Vision Development optometrists

  • Neuro-optometric rehabilitation optometrists

  • Behavioral optometrists

  • Neuro-ophthalmologists

  • Developmental ophthalmologists

  • Specialists in Opthalmological TBI diagnosis, for example, Steve Rauchman, M.D. in Los Angeles

  • CANADA

Insurance issues with Vision Therapy

In the United States, military and government-based insurance policies generally do not cover this kind of vision diagnosis and vision therapy, nor does the managed care consortium Kaiser Permanente. Other insurance policies have a significant limit on "orthoptics", which is the insurance code. Some plans cut off vision therapy at age 11, others at age 18. Some plans limit a person to 32-lifetime vision therapy visits. We spoke with one vision therapy center in our area, which said that the majority of their patients pay out of pocket.


About Vision Therapy

Vision therapy is also referred to as Oculomotor Therapy, or Neuro-Optometric Rehabilitation. The diagnostic exam is typically done by a specialized optometrist, who then writes an individualized treatment plan for the patient. The patient then visits the clinic once a week to work with a vision therapist who makes use of a variety of tools and exercises to train specific aspects of the visual system, improve the accuracy of vision, and return vision to normal after a concussion. They work on functional skills such as eye tracking, focusing, and eye teaming (the way the eyes work together). They will also work on visual discrimination (problems with reversing b's and d's), handwriting, and spatial awareness. The patient is assigned specific home exercises with specialized equipment that is loaned to them. Follow-ups are scheduled for progress exams with the optometrist. Typically patients go to a 45 minute vision therapy session once a week for at least 12 weeks, or longer as needed.

Video produced by the Headway Foundation: "The Eye-Brain Connection: Vision and Concussion." This video features Dr. Bryce Appelbaum, a neuro-optometrist who specializes in vision therapy for concussion recovery. The webinar lasts about 40 minutes including a Q&A at the end.


Visual Midline Shift Syndrome may be causing related neck, shoulder and back pain

Visual therapists study their patient's posture for clues about what specific problems are happening with the eyes. A patient's posture may be leaning slightly to one side and they may have a slight twist of the head. For example, a patient whose right eye isn't able to focus on a near object may develop a posture that twists and leans to the left in an attempt to compensate. This abnormal posture may indicate that the patient has Visual Midline Shift Syndrome which is "caused by distortions of the spatial system causing the individual to misperceive their position in their spatial environment." The result is "a shift in their concept of their perceived visual midline" which then causes a person to lean to one side, lean forward, or lean backward. Visual therapies use a series of specialized exercises to retrain the body. 

It seems plausible that this leaning and twisting are contributors to the chronic neck, shoulder, and back pain experienced by many people with concussions and post-concussion syndrome.


Good Website Resources

Podcasts about Vision Diagnosis and Vision Therapy

Dr. Jessica Schwartz, the host of Concussion Corner podcast, interviews Dr. Neera Kapoor on the role of neuro-optometry in concussion management. Midway into the interview, Dr. Kapoor gives the best description we've heard of the kinds of vision problems people with concussions experience.

Amy Zellmer, the host of Faces of TBI podcast, interviews Kara Christy, occupational therapist, and certified brain injury specialist, about cognitive-perceptual motor retraining and vision therapy.

 

The Concussion Project and has extensive information about concussion vision issues and treatment. Also recommended is the specific page for individuals

Visionhelp.com has links to helpful articles about this topic as well as a doctor search tool.

COVD.org is the College of Optometrists in Vision Development, which has explanations about vision diagnosis and therapy and a doctor search tool.

Neuro-Optometric Rehabilitation Association has some helpful articles plus a doctor search tool.  

MinnesotaVisionTherapy has a good page explaining the vision therapy process. Their program makes use of Light Therapy (Syntonics) which is colored light frequencies to enhance visual processes.

This Lifemark article Vision issues following a concussion - there is hope and help does a good job of describing the different kinds of vision issues and symptoms typical after a concussion. 

Steve Rauchman, M.D., Specialist in Opthalmological TBI diagnosis, has a useful blog about traumatic brain injury, concussions, and vision issues


New Research

"Long-term effects of mild traumatic brain injuries to oculomotor tracking performances and reaction times to simple environmental stimuli"

A University of Vermont article reported on a new study published March 15, 2018.

"Study: Concussions Preventing Veterans, Athletes From Succeeding in College" reports that a "study in Scientific Reports, a journal published by a Nature Research Journal, revealed slower visual and auditory reaction times by veterans and athletes to simple environmental stimuli years after experiencing mTBIs. Participants also struggled with significant reductions in eye-tracking accuracy and were plagued by intrusive saccadic eye movements, making it difficult to focus for even short periods of time."

In the Discussion section of the study itself, it is noted that "It is important to emphasize that our mTBI cohort reported the presence of visual problems (often referred to as visual discomfort) in the Neurobehavioral Symptoms Inventory." In other words, the study compared a cohort (group) of people with long-term effects from mTBI who reported visual problems or discomfort with a group of controls (people) who had not had a concussion. 

From the UVM article: "The study raises serious questions about whether athletes are being cleared to return to the playing fields too soon, and more importantly if veterans are returning to active duty while still experiencing cognitive impairments and abnormal eye movements...[Students] never realized they were missing class materials because their eyes were not moving in space effectively, which led to missing lines of text in the presentations...

Once post-concussive symptoms are identified, researchers hope to develop ways to improve academic performance for veterans and athletes. [Study co-author Sambit] Mohapatra says some basic changes in teaching can have a major impact. For example, one veteran was missing lines in PowerPoint presentations due to poor eye-tracking ability and became frustrated when not performing well on tests. By simply printing out the PowerPoint and having the student underline every single line as the faculty member reads it solves such a problem, says Mohapatra."

 

Several vision-specific concussion tests have been developed, which points to the regular involvement of vision problems in concussions. Originally developed with a grant from the NFL, the portable I-PAS system looks like a virtual reality headset and measures eye movements with video and computers; it can diagnose concussions with 95 percent specificity. The device was approved by the FDA in May 2018 and is now a required part of the concussion testing at the Indianapolis Motor Speedway.  The research on a CBD pill at the University of Miami will use the I-Portal goggles to diagnose concussions as part of their clinical trials. A simple sideline concussion test that parents can use is the King-Devick test, which involves reading a specific pattern of numbers from left to write while being timed with a stopwatch; the 2015 study on the test notes that "concussion is associated with many neuro-ophthalmologic signs and symptoms."