Abstract: The wars in Afghanistan and Iraq have been notable for the high rates of traumatic brain injury (TBI) that have been incurred by the troops. Visual impairments often occur following TBI and present new challenges for rehabilitation. We describe a neurological vision rehabilitation therapy that addresses the unique needs of patients with vision loss that is due to TBI.
The wars in Afghanistan and Iraq have been notable for the high rates of traumatic brain injury (TBI) that have been incurred by the troops (Hayward, 2008). The need to develop effective rehabilitation strategies has been highlighted by service members who are returning with visual deficits secondary to brain injury. In 2003, the Western Blind Rehabilitation Center (WBRC), a center-based program at the Palo Alto Veteran's Affairs (VA) Medical Center, began to admit service members with neurological visual impairment, many of whom had "polytrauma" injuries. Polytrauma injuries are defined as multiple injuries, occurring simultaneously, in which one or a combination of injuries are life threatening. The injuries can include traumatic amputations, burns, penetrating injuries to one or more areas of the body, infections, paralysis, internal injuries resulting from a blast wave, and damage to the sensory organs (Ritenour & Baskin, 2008). TBI often accompanies polytrauma injuries and can range from mild to severe (Belanger, Kretzmer, Yoash-Gantz, Pickett, & Tupler, 2009; Taber, Warden, & Hurley, 2008). In these patients, TBI is often associated with a blast-related event, such as an improvised explosive device or a rocket-propelled grenade. However, brain injury can also result from gunshot wounds, motor vehicle accidents, anoxia, stroke, and other causes. The visual symptoms of a blastrelated TBI are often similar to the symptoms presented with other mechanisms of injury, such as stroke, motor vehicle accidents, falls, and assaults (Belanger et al., 2009; Brahm et al., 2009).
Patients with TBI at the Palo Alto VA often present with visual impairments and dysfunctions resulting from an injury to the brain, rather than a direct injury to the eye or orbit (Brahm et al., 2009; Cockerham et al., 2009; Goodrich, Kirby, Cockerham, Ingalla, & Lew 2007; Lew et al., 2007; Lew et al., 2009; Stelmack, Frith, Van Koevering, Rinne, & Stelmack, 2009). Injury to the brain will produce visual symptoms, depending on the area or areas of the brain in which damage occurred. Brain injury may result in reduced visual acuity, loss of a visual field (such as the nasal or temporal field and quandranopia and hemianopia either in the superior or inferior field), and binocular vision disorders. Accommodative dysfunctions, convergence insufficiency, and ocular motor deficits are examples of binocular vision disorders (Brahm et al., 2009; Goodrich et al., 2007; Lew et al., 2007). Functional implications of binocular vision disorders include reading difficulties (such as losing one's place, comprehension, and endurance), diplopia, eye fatigue, gait and postural imbalance, attention, and concentration.
The treatment of patients with neurological visual impairment secondary to brain injury can be challenging. For example, patients may have physical injuries and other limitations, including amputation, weakness, paralysis, or apraxia (the inability to carry out purposeful movements). Also challenging are the cognitive, language, and psychosocial issues that often accompany severe injury. The cognitive skills that may be affected include memory, judgment, mathematical skills, attention, and decision making. Language skills may also be affected in patients who are diagnosed with aphasia, the inability to produce or comprehend language. In many cases, the psychosocial issues that these patients face make the rehabilitation process more challenging. These issues may include posttraumatic stress disorder (PTSD), depression, anxiety, and sleep disorders (Vanderploeg, Belanger, & Curtiss, 2009). …