How to Vestibularly Make Optometric Vision Therapy More Effective COPE # Pending COVD 44 th Annual Meeting October 23, 2014

Transcription

1 What Kinds of Patients Might Benefit? How to Vestibularly Make Optometric Vision Therapy More Effective COPE # Pending COVD 44 th Annual Meeting October 23, 2014! Screaming child in reception area! Patient comes to VT and appears fatigued! Patient demonstrates poor posture! Slow Reader! Effects upon ocular motor skills, binocularity! Effects upon gaze palsy, nystagmus! Dizziness and vertigo Curtis R. Baxstrom, MA, OD, FCOVD, FNORA Importance of Vestibular Processing! Sensory Integration Jean Ayres, PhD! Activate and Calm your patient! Critical to Development over the Lifespan! First myelinated system! Sleep cycles, Moro Reflex! ADD/ADHD, ABI and Geriatric populations! Critical to Balance and Equilibrium! Visual, Motor and Vestibular Processing Functions of Vestibular Processing! Arousal and Calming in a car! Extensor Tone against gravity and flexion! Cocontraction flexion/extension! *Equilibrium Responses - cerebellum! *Gravitational Security integration of reflexes Functions of Vestibular Processing! Bilateral Coordination! Reciprocally related to vision and motor! Eye Movements! Sets tone for EOM, low tone and CI! Stability for visual information processing! Feedback for stability of head and body, thus allowing cognition to be free of postural control Vestibular System! Peripheral Vestibular System! Semicircular Canals rotational input, phasic " Stimulatory-Arousal! Otoliths linear input, tonic " Calming! Do these really ever work in isolation?! Central Vestibular System! Unilateral vs. Bilateral concerns 1

2 Vestibular Physiology Semicircular Canals - Otoliths 7 Vision and Vestibular Processing Canal Function is Related to Head Position Semi Circular Canals - Stimulation SCC Input to EOM s 2

3 14! Arousal and Emotional Status! Processing Speed / EOM Performance! Bilateral Processing / Reciprocal Interweaving! Phorias / Fusional Reserves! Strabismus! Paresis / Palsy! Decompensating Phoria! Others! Linear Acceleration is Calming Exotropia?! Swing, Trampoline! Rocking chair, Walking rail! Rotational Acceleration is Excitatory Esotropia?! Swing, Computer chair, Standing! Turn and Clap! Turn and Catch! Bilateral Processing / Reciprocal Interweaving! Postural control (increases extensor tone)! Visual Neglect / USI see Karnath! Reading language and comprehension, goal is to increase reciprocal interweaving! Processing Speed and EOM Performance! DEM, Michigan Tracking, Visagraph Bean Bag Activity - Bilateral " Choose assessment tool (DEM, Michigan Tracking, Oral Reading, Visagraph, etc.) " Bean Bag 20X, Head only " Bean Bag 20X, Eyes only " Recheck findings after input, include scores and behavioral observations " *Modify bean bag activities as you wish " for more info 3

4 Why Might This Improve Reading?! Increased arousal/alertness! Bilateral Integration (alternate R/L)! R Hemisphere Comprehension! L Hemisphere Language! Combined = Efficiency in Reading! Spatial Activity similar to reading?! Improve processing speed, timing! Cerebellum?! Smoother enunciation! BINOCULAR Treatment Options! Bean Bag, Turn and clap, Head movement during Tx, Therapy done in a swing! Phorias and Fusional Reserves! Strabismus Intracranial Hemorrhage (ICH)! Decompensating Phoria! Quadriplegia infants and geriatric pop.? How Can You Decrease Phorias?! Horizontal, Vertical and Cyclotorsional! OMD s suggest you cannot change the motor component and thus recommend surgery! This leads back to strabismus. Vision therapy does not simply provide fusional ranges to compensate for the patients phoric posture.! Two Important methods to help change posture:! Jump Ductions (Ludlam)! Visual-Vestibular Input Changes In Binocularity! Decrease H, V and Cyclo Phorias! Can also increase fusional ranges of BO/BI! If patient not making gains, another tool!! Increases peripheral/spatial awareness and/or decrease suppression (motion?)! KEY is ADDING Vestibular Input to your already efficacious vision therapy routines Visual-Vestibular Therapy! Vestibular input can be effective in your treatment plans of common binocular conditions such as phorias, fusional reserves and strabismus. How about other conditions like:! Paresis/Palsy with Strabismus! Decompensating Phoria! Quadriplegia with Diplopia 4

5 Paresis / Palsy Cases! Extend ROM monocularly! Sector Occlusion (why not start with prism?)! Pursuits, Saccades, OKN, VOR-direct/indirect! Then consider compensatory prism! Minimum to fuse! Add vestibular rotational, decrease prism over time, goal is to fully remove! Consider ground in residual prism if necessary Vestibular Input for L CN6 Paresis/Palsy! DIRECT Effect Occlude right eye, rotate slowly right 10X eyes open, fixate objects during rotation (look at room corners)! PRN Effect Occlude right eye, rotate left 5-10X eyes closed, stop and open left eye, PRN should be present, fixate objects to left and add touch for proprioceptive localization! Goal is for full range of movement, then prism Overall Tx Plan L CN6 Paresis! Extend ROM of L CN6, nasal/binasal to eliminate diplopia! Consider pursuit and saccade therapy as well as OKN, not simply horizontal-add up/down! Once improved, consider minimal fresnel prism! Add visual-vestibular activities (turn and catch, bean bag toss, etc.) and decrease prism! Goal is to remove all prism Decompensating Phoria! Appears to be increasing in the population! Vertical > Horizontal?! Literature suggests compensatory prism! The question is what is leading to this?! Consider young infants with intermittent strabismus and geriatric population, what are the similarities? Decompensating Phoria! Skeffington suggested vertical decompensations were related to accommodative concerns! If you decrease movement you have decreased vestibular input, less tone information to EOM! What if you recommend increased vestibular input to address the specific EOM that appear to be affected? (via Park s 3 Step)! *Don t forget Jump Duction work! (Ludlam) Decompensated Phoria - Case! Concussion at 12yo, now 16 and symptoms of intermittent diplopia began with increased school demands 2 months prior! Park s 3 Step suggests Right Superior Oblique STIMULATION SET UP from Leigh and Zee ***Isolate SCC to EOM, eyes open vs. closed! Chin 30 degrees down, L head tilt 45 degrees! Rotate Right, Right Posterior Canal RSO! Rotate Left, Left Anterior Canal RSO 5

6 Decompensated Phoria - Case! Initial Distance Vertical Phoria 7/7/7 R Hyper Post R Rotation 4/4/4, Post L Rotation 3/2/3/2! 3 weeks later 4/3/4/3 Post R Rotation 3/3/3, Post L Rotation 2/1/2/1! 3 weeks later 3/2/3/2 Post R Rotation 2/2/2, Post L Rotation 1/0/1/0! D/C Tx 8 weeks total, added bean bag 1X day! 1 month later 1/1/1, 3 mo. Later 1/0/1 Diplopia Treatment for Quadriplegic! Central/Peripheral Awareness! Broadcaster is diplopic, how about TV?! Increase peripheral awareness, alternate C/P! Blinking often minimal, 1X every 5 seconds! Vestibular Input! KEY is lack of head movement! Add 5-10 X dolls eye watching TV! Apply to regular VT patients with decompensating phoria To Dizziness, and Beyond 6

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8 Direct VOR Stimulation of Canals to EOM-interpreted from Leigh and Zee CANAL ROTATION DIRECT EFFECT PRN EFFECT 1 eye closed both closed Lateral Canal Rotate R RMR, LLR LMR, RLR Rotate L LMR, RLR RMR, LLR 45 degree tilt R Right Anterior Rotate R RSR, LIO RIR, LSO Left Posterior Rotate L RIR, LSO RSR, LIO 45 degree tilt L Right Posterior Rotate R LIR, RSO LSR, RIO Left Anterior Rotate L LSR, RIO LIR, RSO