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Combining vision education and physical therapy for hemianopsia: A case study.

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Visual impairment resulting from a cerebral vascular accident typically alters an individual's ability to function independently. A visual field cut severely impacts one's ability to read, perform activities of daily living and navigate safely in the environment. Living independently is typically no longer an option. This is a major challenge on families and one's ability to make progress in a multitude of areas.
 
Presenting the Case

The patient was a 55-year-old male who was married and worked as a senior manager at the time of his stroke. The patient suffered a right carotid artery dissection resulting in a right middle cerebral artery tertiary embolic CVA with complete occlusion of the right carotid artery. He presented with dense left hemiparesis, left neglect and field cut, and left spastic hemiparesis. He underwent intensive rehabilitation at both inpatient and outpatient facilities as well as home care.

In May 2011, he underwent a Zeiss Humphrey Visual Field Test and the results did not show clinically significant change from the previous field test, which indicated a left field cut. After the results of this test, he was informed that his vision would probably not improve much more since he was almost two years post-stroke. He was self-referred for physical therapy and vision exercises in November 2011.

At the time of referral, he presented with left neglect, attention and memory deficits, severe decrease in executive function skills, paralysis of the left upper extremity with decreased sensation and proprioception, and independent ambulation with large based quad cane and an AFO on the left ankle on level surfaces. He had decreased weight shift to the left and his posture was kyphotic with head turned to the right. He did not make eye contact when speaking and required full assist for bathing and dressing. He wore a prism in the left lens.

The patient's goals at the time of evaluation in November of 2011 were to drive a golf cart, drive a car, get out of bed independently, go up and down stairs independently, dress himself, crawl on the floor, and increase left arm mobility with regain of function.

Methods Used

Standard physical therapy procedures were used to teach stair climbing, beginning with a strength and endurance program using a recumbent stationary bicycle and weight training. Using the basic premise of neuroplasticity of "neurons that fire together wire together", natural vision education techniques were combined with a combination of mathematical computations, ball skills and rhythm and timing at a level that was comfortable for the patient and slowly became more challenging.

Using charts created by Ray Gottlieb, OD, PhD, for attention and memory training, the rehabilitation program was progressed from basic number recognition to addition and subtraction in conjunction with balance and ball skills. Initially the patient had difficulty tracking the numbers on the chart. He would lose his place frequently. Visual and tactile cues were provided to assist him with understanding and tracking columns of numbers. An eye exercise program was initiated to increase the range of motion and neck rotation to the left.

Highlighted arrows were placed in all extremes of direction to target full and complete range of motion. Natural vision exercises including palming, visualization, blinking, breathing, patching and a nose card to increase peripheral vision were used. Ball skills and bean bag skills were performed with attention to the left visual field. A hanging ball was used to track a moving target in the peripheral field. Binocular exercises were instructed using the finger gate technique.

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The exercises were performed with the physical therapist three hours per week over the course of a six month time period. The patient was provided with a home program that was altered on a weekly basis.

Results

By April 2012, the patient returned to his optometrist. The Zeiss Humphrey Visual Field Test was performed and showed no field cut. At that time, the patient was going up and down stairs independently, getting down and up from the floor with supervision, dressing his lower body and requiring assist for his shirt, getting out of bed independently, and able to knee walk on the floor. His reading ability returned to normal. He was able to safely drive a golf cart and successfully track all of his drives from his golf game. He signed up for a driving rehabilitation program and began addressing his left arm function more intensively.

Discussion of Case

Physical therapists can enhance the rehabilitation process by incorporating natural vision techniques into their treatment programs. Visual acuity, as well as peripheral vision, binocular vision, tracking, visual perception, balance, memory and attention, are key factors in the success and functional outcome of a rehabilitation program.

As lengths of stay are shortened and the majority of functional return is achieved within one year of experiencing a cerebral vascular accident, it is critical for the therapist to explore vision as a tool for accessing brain rehabilitation. It is also important to not hold on to the ancient belief that a person will not continue to make large functional gains beyond the one year post-stroke period. Neuroplasticity is not on a continuous timeline and patients are unable to achieve this outcome through an independent home exercise program. Intense physical therapy combined with natural vision techniques provides a comprehensive approach to brain injury rehabilitation.

A quote from the case study participant: "From the beginning of my rehab work, numerous doctors and therapists talked to me about the plasticity of the brain. Recognizing that this is not an exact science yet, I have anxiously waited for some kind of a sign that my brain is going to remap and relearn things. The dramatic improvement in my vision just gave me the proof I wanted to see and the motivation to work even harder for as long as it takes. Another unexpected benefit from this is hope."

Resources

Battenberg, J., & Rigney, M. (2010). Eye Yoga, Landon Street Press.

Gottlieb, R. (2005). Attention and Memory Training, Optometric Extension Program.

Mary Wilkins is a physical therapist in Auburn, ME. She graduated from Northeastern University in 1983 with a bachelor of science in physical therapy. She is licensed to practice physical therapy in Massachusetts and Maine. She is self-employed at her practice KIDS IN MOTION INC. She contracts to schools and rehabilitation facilities. She became certified as a vision educator in July 2012. She can be contacted at mary.wilkins@myfairpoint.net.



     

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