NeuroRehabilitation

Visual dysfunctions are common in individuals following concussion/mild traumatic brain injury (C/mTBI). Many deficits have been uncovered in their oculomotor system, such as in the pupil and accommodation.

To describe the static and dynamic abnormalities in the pupillary and accommodative systems in those with C/mTBI. This includes both diagnostic and therapeutic aspects, with emphasis on objectively-based test findings, as well as their basic and clinical ramifications.

PubMed, Google Scholar, and Semantic Scholar databases were searched from 1980–2020, using key words of accommodation, pupil, vision therapy, vision rehabilitation, and objective testing, for peer-reviewed papers, as well as related textbooks in the area, in those with C/mTBI.

For both systems, most static and dynamic response parameters were abnormal: they were typically reduced, slowed, delayed, and/or more variable. Most of the abnormal accommodative parameters could be significantly improved with vision therapy.

For both systems, most response parameters were abnormal, which could explain their visual symptoms and related problems. For accommodation, the improvements following vision therapy suggest the presence of considerable visual system plasticity, even in older adults with chronic brain injury.

Individuals who have suffered a concussion/mild traumatic brain injury (mTBI) frequently report symptoms associated with vestibular and/or oculomotor dysfunction (VOD) like dizziness, nausea, fatigue, brain fog, headache, gait and neurocognitive impairments which are associated with the development of chronic symptoms. The Vestibular/Ocular Motor Screening (VOMS) tool has been established as a reliable and clinically relevant complement to use alongside a battery of post-concussion tests to improve screening and referral for further evaluation and treatment of VOD.

This paper will review the pathoanatomy and symptomatology of common vestibular and oculomotor disorders after concussion, as well as the utility of the VOMS to assist in diagnosis, referral, and management.

Primary articles were identified using a search via PubMed, Google Scholar, OneSearch, and CINAHL. Search key terms were combinations of “mild traumatic brain injury” or “concussion” or “pursuit” or “accommodation” or “vergence” or “convergence insufficiency” or “saccades” or “vestibulo-ocular reflex” or “vestibular ocular motor screen” or “vestibular rehabilitation”, or “vision rehabilitation” including adult and pediatric populations that were published in print or electronically from 1989 to 2021 in English. Classic papers on anatomy of eye movements, vestibular system and pathological changes in mTBI were also included, regardless of publication date.

Objective impairments are commonly found during testing of smooth pursuit, saccades, vergence, accommodation, vestibular ocular reflex, and visual motion sensitivity after mTBI. These deficits can be actively treated with vestibular physical therapy and oculomotor/neuro-optometric vision therapy. VOMS is an efficient and reliable tool that can be used by all healthcare and rehabilitation providers to aid in diagnosis of post-concussion VOD, to help facilitate the decision to refer for further evaluation and treatment to expedite symptomatic post-concussion recovery.

VOD is common after concussion in acute, post-acute, and chronic phases. Once areas of impairments are identified through proper assessment, clinicians can maximize recovery by referring to vestibular physical therapy and/or neuro-optometry to design a targeted treatment program to address individual deficits.

Post-traumatic headache is the most common sequela of brain injury and can last months or years after the damaging event. Many headache types are associated with visual concerns also known to stem from concussion.

To describe the various headache types seen after head injury and demonstrate how they impact or are impacted by the visual system.

We will mirror the International Classification of Headache Disorders (ICHD) format to demonstrate the variety of headaches following brain injury and relate correlates to the visual pathways. The PubMed database was searched using terms such as headache, head pain, vision, concussion, traumatic brain injury, glare, visuomotor pathways.

Every type of headache described in the International Classification of Headache Disorders Edition III can be initiated or worsened after head trauma. Furthermore, there is very often a direct or indirect impact upon the visual system for each of these headaches.

Headaches of every described type in the ICHD can be caused by brain injury and all are related in some way to the afferent, efferent or association areas of the visual system.

Photophobia is a common sensory symptom after traumatic brain injury (TBI) that may have a grave impact on a patient’s functional independence, neurorehabilitation, and activities of daily living. Post-TBI photophobia can be difficult to treat and the majority of patients can suffer chronically up to and beyond one year after their injury.

This review evaluates the current theories of the pathophysiology of photophobia and the most-common co-morbid etiologies of light sensitivity in TBI to help guide the differential diagnosis and individualized management of post-TBI photophobia.

Primary articles were found via PubMed and Google Scholar search of key terms including “photophobia” “light sensitivity” “photosensitivity” “photo-oculodynia” “intrinsically photosensitive retinal ganglion cells” “ipRGC” and “concussion” “brain injury” “dry eye”. Due to paucity of literature papers were reviewed from 1900 to present in English.

Recent advances in understanding the pathophysiology of photophobia in dry eye and migraine and their connection to intrinsically photosensitive retinal ganglion cells (ipRGC) have revealed complex and multifaceted trigeminovascular and trigeminoautonomic pathways underlying photophobia. Patients who suffer a TBI often have co-morbidities like dry eye and migraine that may influence the patient’s photophobia.

Post-traumatic photophobia is a complex multi-disciplinary complaint that can severely impact a patient’s quality of life. Exploration of underlying etiology may allow for improved treatment and symptomatic relief for these patients beyond tinted lenses alone.

Tinted lenses have been used to manage visual discomfort and photosensitivity in patients with migraines, benign essential blepharospasm (BEB) and epilepsy.

The purpose of this review is to examine the existing clinical research regarding the use of colored filters among patients recovering from traumatic brain injuries.

A review of English articles from PubMed, Embase from embase.com, Web of Science, APA PsycINFO (OVID), Scopus, and Cochrane Central Register of Controlled Trials with publication years from date of inception to June 10, 2021 was performed. Articles were first screened by title and abstract, followed by full-text review. The search strategy resulted in 7819 results. The final analysis included seven articles which discussed the use of tinted lenses in patients post-traumatic brain injury.

While there is a paucity of information related to the therapeutic use of tinted lenses to mitigate post-traumatic light sensitivity and migraines, patients will subjectively report improved symptoms, specifically with precision tints or FL-41.

Further studies are needed to understand the mechanism of action as well as objective and subjective benefits of tinted lenses in patient post-traumatic brain injury.

Disorders of higher visual processing often impact patients with acquired brain injury. Even with treatment, these vision conditions can cause chronic challenges for patients. Understanding these conditions and their management can help improve functional independence and quality of life.

To discuss the various disorders of higher visual processing that result from acquired brain injury. Discussion to include classification, evaluation, and treatment techniques available to clinicians.

Peer reviewed journal articles were searched, primarily through PubMed. Articles spanning several decades were included in the review for historical context of these conditions, however an emphasis was placed on more recent publications for purposes of a discussion regarding clinical management of these conditions.

Peer-reviewed articles and clinical trials from across several disciplines were included to frame a discussion of this varied group of conditions.

Visual processing disorders have debilitating impacts on both the rehabilitation process as well as functional independence. Varied approaches are utilized in the treatment of these conditions with limited success. Understanding the benefits and limitations of both restorative and compensatory treatments will better help clinicians manage patients with these conditions.

Sexual dysfunction (SD) is experienced by 50% of stroke survivors, and it is identified as critical in their rehabilitation management, but often remains unaddressed.

To evaluate the effectiveness and adverse events of currently available interventions for SD following stroke.

A summary of the Cochrane Review by Stratton et al. 2020, with comments from a rehabilitation perspective.

Three randomized control trials with a total of 212 participants were included. Evidence quality was very low for all assessed interventions (pharmacological, psycho-educational and physical therapy). The efficacy of pelvic floor muscle training for lower urinary tract symptoms and erectile dysfunction remains uncertain. Pharmacological interventions may improve sexual functioning, while psychoeducation show little to no difference on sexual functioning outcomes.

The effectiveness of current rehabilitation interventions for SD following stroke remains uncertain due to the low quality of evidence and limited sample size. Further studies with improved methodology should investigate rehabilitation interventions for SD in stroke survivors to improve their quality of life.