By Debbie Killion, COVT
Imagine this: you are a 54 year-old RN who was involved in a motor vehicle accident. This accident caused you to suffer a concussion that kept you out of work for six months. You completed three months of physical therapy, occupational therapy, and speech therapy, which included vestibular and motion sensitivity rehabilitation. It’s been almost a year since your accident and you continue to suffer from eyestrain, fatigue, and loss of place when reading, as well as motion sensitivity. In addition, you have lingering difficulty with depth perception, balance and moving objects. You are dizzy whenever you get in a car or are in crowds of people. What would you do? You guessed it-you find a behavioral optometric practice and try vision therapy!
Vision therapy can be an effective treatment for concussions, which frequently involve visual side effects. Often our patients have already participated in various other therapies such as physical, occupational, vestibular, cognitive and speech. Even after these other therapies are completed, the patients who find their way to us continue to report symptoms. The unpredictability of these symptoms makes their rehab all the more frustrating.
Recovery is not linear for these patients. Instead, it is a series of ups and downs, especially early in therapy. Patients come to us feeling frustrated by their continued symptoms and are scared that they may never feel better again. We set their expectations so they know their recovery will be a bit of a “roller coaster” in the beginning—there is no quick fix. But we also work to stay positive and to reassure them that they will get better.
Our patients’ rehabilitation actively takes into account the erratic nature of their symptoms. Because vision therapy activities can sometimes temporarily increase or intensify symptoms, we monitor them throughout sessions. We ask patients to rank their symptoms such as headache, eyestrain, dizziness, and nausea on a scale from 1-10 before, during, and after each vision therapy session. In addition, with highly symptomatic patients, we suggest they keep a diary at home to help identify symptom triggers. In this way, we can better track their progress and determine when to decrease or increase therapies.
We stimulate brain circuits to promote recovery, but must not push too hard in a VT session or there can be a setback. Setbacks may come within a few minutes or hours, that night, or even the next day. We monitor symptoms frequently throughout VT sessions and receive constant feedback from our patients. We do not assume anything, instead we ask, ask, ask! Everything is documented in chart notes so we can refer back to where their strength or weakness lies.
At the beginning of VT, when their symptoms spike more than two levels from where they started (their baseline), we take a break. Continuing therapy when symptoms get significantly worse can cause symptoms to last longer, so we rest and recover. Breaks are determined by each patient – when their symptoms return to baseline levels, we restart therapy. Throughout VT, our protocol is “rest, recover, restart.”
We administer the Acquired Brain Injury Convergence Insufficiency Symptom Survey (ABICISS) and the COVD QOL questionnaire at the initial VT session as well as at any reevaluations, which helps monitor our patients’ symptoms from start to end points in therapy. It also helps to present our patients, or their parents, with evidence of improvement.
As patients progress in therapy, recovery tends to accelerate more quickly than in the beginning stages. My goal, as a therapist, is to eliminate their symptoms or, at the very least, help them to become more aware of triggers and enable faster recovery from their effects. Before they start VT, their debilitating headaches and eyestrain can significantly affect daily activities. By the time they are done, they have relearned their ability to read, drive, take notes in school or play a sport – all with less symptoms or none at all!
Remember the brain injury patient described at the beginning of this article? Her name is Clara, and I am happy to report that she completed twelve sessions of VT to remediate her post-concussion convergence and ocular motor problems. She states that reading feels much easier and all of her post-concussion symptoms of eyestrain, fatigue, loss of place with reading and motion sensitivity were eliminated. She is thrilled to be back to work and her life again! Vision therapy works!