Vision Therapy – Post Concussion Syndrome

Vision Therapy – Post Concussion Syndrome


they say that around 60% of concussions
can impact vision but what exactly does that mean over the course of the next
hour what we’d like to do is to let you in on a lecture where we discuss post
concussion syndrome and the visual impacts that it can create what we’re
going to namely be talking about is our Canadian Journal of optometry study on
post concussion syndrome and we’re going to be presenting it using language that
should communicate with a wide audience be the optometrists ophthalmologists
allied professionals or insurance adjusters essentially anyone who even
has a passing interest in vision should find value in viewing what we found
within our post concussion cohort was that an initial presentation these
individuals were presenting at around 40 percent of age normalized visual
function so we’re going to take you through exactly what that means the
tests that we use and how the results of these tests could impact function after
use of therapeutic glasses which will describe within the talk and generally
between 15 to 20 sessions of in-office vision therapy what we found was that
the same cohort was now operating at about 95 percent of age normalized
function and had seen a 50% reduction in visually derived symptoms you can
imagine that with this improved visual performance they would see gains in
their ability to return to school return to sport or return to work so we really
do appreciate you tuning in and of course if there’s any questions that
this lecture doesn’t it doesn’t address please feel free to reach out via our
website Okanagan vision therapy dot CA thanks so much for tuning in basically
what we’re hoping to talk about here are what are the statistical trends that we
can expect to see within post concussion syndrome and what sort of changes can we
expect to see following vision therapy or use of therapeutic glasses or
training glasses and talk a little bit more about what that is so when they
talk about concussions they often talk about it being the the hidden disability
so you know you can see someone they look fine you know they look healthy but
they’re really hurting in the struggling and I would argue that the
functional visual impact as we said with the title here is almost an invisible
deficit and the beautiful thing about what we can do as optometrists is we
have the ability to measure what would be considered invisible and communicate
with other practitioners on a very objective scientific basis regarding
what it is that we’re seeing I spend a lot of time you know lecturing with non
optometric professionals so physiotherapists and occupational
therapists and psychologists and lawyers and just anyone who’s as even kind of a
passing interest in vision training and so it’s really nice to kind of come back
and speak with optometrists and kind of speak my native language you know we can
kind of speak a bit more optometric ease and kind of how we can communicate that
to other professionals and pass that pass that along so in terms of the basis
for this presentation over the last number of years I had started to notice
there’s patterns in terms of how post concussion syndrome presents so at the
clinic we probably I think I mentioned we probably see somewhere between four
and five hundred concussions a year and what I was noticing was there’s these
very common trends that you start to see in the optometric data when someone has
post concussion syndrome and as a result of those trends you can see outline a
treatment plan or you can get them in the direction of somewhere to get help
so following concussions one of the interesting things we know that in in
the adults population about 50% of concussions are going to have some type
of visual impact and in the adolescent population it is closer to 70% so we
know how much of the brain is used for visual processing estimates of at least
50% if you look at the neurology it’s almost our entire brain is in some way
involved in vision involved with moving the eye the eyes involve the visual
processing and as a result of that it’s extremely common for vision to be
impacted one of the other things that you find is that because there’s so much
processing power that goes into vision it tends to be one of the slowest
systems to recover and as a result you have people who’ve worked through a
variety of things that are very important to work on
some of them might be life-threatening some of them might be musculoskeletal
they’re working on other areas but vision kind of tends to linger and so as
I mentioned I think it’s it’s our responsibility as optometrist to do what
we can in order to to uncover what I had listed here is sort of the the invisible
deficit so I had to list there’s no disclosures this is all data from our
clinic actually it’s interesting you know for we’ve been VT only for about
three years and I don’t think we’ve had a rep in three years come by so it’s
it’s it’s pretty pretty crazy when you get rid of I guess drops and lenses it’s
like you fall off the face of the earth so but long story short there’s this is
all kind of data that’s coming from our clinic now there’s a lot of amazing
companies that work with envision therapy but none of them are sponsoring
the talk or anything so I sort of already alluded to this I go to a lot of
vision therapy continuing education and I think that we do a really good job of
communicating our why you know I think people know why we offer vision therapy
you know it’s to change lives it’s to better lives is to change the trajectory
of of someone’s performance I think the area that I’m hoping that I’m hoping to
work on today is to talk a little bit more about the what you know what is
sort of the the meat that drives what it is that we’re doing how do we know what
needs to be done in terms of vision training how do we know when we’re
finished in terms of doing vision training and how do we measure our
performance and how do we we measure things initially so again a lot of this
is objectively drape driven and I want to take everyone through the types of
things that you can add to your exam in a matter of three minutes that will give
you a ton of information about the status of someone’s visual recovery so a
lot of this data pretty much all of this data is coming from a study that we have
coming out in the next couple months in the canadian journal of optometry which
is the effective vision therapy on measures of ocular motor function of
patients presenting with post concussion syndrome so it’ll either be coming out
in June or September but it’s basically looking at the analytics of concussions
and then the results that happen after someone has has enroll
their work through vision therapy so again any of you want to kind of dive
into the P values and the T scores and all of the statistics of course although
that’s going to be available today we’re gonna be talking about what the
important general findings are so when we talk about visual rehab or visual
rehabilitation I wanted to start by telling a little bit of a story because
I think that this will put us a little bit in terms of the the framework of
what it is that happens in general rehab and an area where I would like to see
improved performance in the visual in the in visual rehabilitation so the
story kind of begins it was about two years ago and I was playing a really
intense game of div three beer league softball
it was very intense I was running between second and third base and I
ended up kind of going for to slide into third and I caught my ankle on the base
and it inverted entirely sideways just disgusting it was sort of one of those
90-degree things kind of just hanging off I was limping to the dugout
afterwards and as a result of that I got an understanding of what happens in
terms of rehabilitation the worst single straightest I wasn’t I wasn’t safe I was
out too so it was that it kind of insult to injury but in terms of my in terms of
my process of rehabbing my ankle the first thing that you generally do is
immobilize so we do that with vision too as well you know you’re usually for the
first week or two you’re limiting how much screen time you’d use how much
computer use that you do you don’t sit in a dark room we know that now because
you need to move to get better and the people who move within the first couple
weeks are less likely to fall into post concussion syndrome but that being said
you still you still be smart about it you know you might limit classroom time
you might limit your workplace hours the amount of talk time that you’re going
there but you go through a little bit of a phase of immobilization the same thing
with my ankle there the next thing that you work on is movement and flexibility
right so generally what what I might have been doing was some dorsiflexion
and plantarflexion with my ankle trying to rebuild that that range of motion
slowly so how can we build that range of motion I might
do some light kind of balance things some proprioception I’m just trying to
rebuild that range of motion and a lot of that stuff is being done there’s a
lot of people who understandably are incorporating vision in terms of their
their rehab program it’s out of necessity you know you can’t do
vestibular rehab without involving the eyes a lot of chiropractors are doing
kind of initial vergence work whether it’s brach stirring whether it’s heart
chart letter charts they’re working on these systems because you absolutely
need to do that you have to work on movement you have to work on flexibility
you have to work on saccades pursuits you just have to get the eyes moving in
that sort of initial phase and a lot of allied professionals are doing this and
they’re doing doing a great job of getting that and you know that initial
sort of phase of recovery underway as someone starts to get into further into
you know their state of concussion maybe two or three months one of the areas
where I start to see we as optometrists play a really really big role is in the
third phase of the recovery and this is an area right now that I’d really like
to see change over the next four or five years you know with with my baseball
injury you don’t go you don’t go back to playing sport right away you have to
work on proprioception you’re working on balance you’re working on movement under
stress you’re mimicking sort of the game play and what happens in envision is a
lot of times people are moving straight into our return to play without being
certain that they have the endurance the stability or the stress tolerance in
order to handle what it is that’s about to come their way so how do we as
optometrists measure endurance stability and stress tolerance because we’re sort
of unique in that we’re one of the major professions that actually has that
ability to measure those three metrics it’s really hard to measure again these
sort of main categories if you don’t have the types of tools that we have
that sometimes we take for granted whether it’s a vergence range or an
accommodative facility these tools can be extremely extremely valuable in the
post-concussion community and in terms of the rehab we have that ability to add
this third phase phase of recovery and I think that I think this is where we’re
vision therapy really does does shine and come into play so as I’ve said you
know in my experience I think this is this is
potentially the area that’s missing in terms of a lot a lot of people’s
recovery it’s that invisible deficit that I think we’re you know as long as
we are screening well and people are know they know to get their eyes checked
and we know exactly what to test for we can make sure that people find the right
direction in terms of building this moving forward so as I mentioned to you
you know we see a lot of concussions we see a lot of head injuries as I
mentioned you know four to five hundred or so a year and what we found is what
what I wanted to do was I wanted to get an idea of what I was seeing I wanted to
get statistics I wanted to have an understanding of what it is in
particular that you can expect to see in post concussion cases so what we did is
we we did kind of we looked back at our results from back in about 2017 and we
took a look at people who enrolled in vision therapy and where vision therapy
was the main mechanism of treatment that we were going to go into and we took a
look at their statistics we looked at all of the different findings and we
sorted out what are the types of findings you can expect to see pre
injury and when you find these sorts of findings what can we expect after doing
some form of vision training so you can see here in terms of the demographics of
the group we looked at within this study again we see a wide variety of people in
general but this was kind of the cohort we looked at in the study the average
age was about 42 years so ranged from 12 to 62 so a pretty wide range so what can
we say about the like a 42 year old in terms of the phase of life that they’re
in right these are the you know they might be having in terms of kind of
their their personal performance these are the these are the providers for
their family meaning that if they’re not in a position to return back to work or
if they are if they do return to work but have no gas in the tank at the end
of the day their families are suffering it’s it’s it’s really kind of
heartbreaking within this particular age group but again we also have some
complicating factors of accommodation changes all of that sort of stuff so
teasing out whether this is presbyopia or
post-concussion will hopefully be able to go through some things that can help
you do that so time since injury I’m very thankful that this has come down in
the last couple years but in 2017 the average I was seeing people was 15
months post injury which that’s you know that’s just too long it doesn’t mean
that you can’t recover things fortunately you know I said the range is
two to thirty months but you know in 2018 we were down to about eight months
as our average and now this year we’re close to closer to around five months
post injury just through education and getting out there and the sweet spot
kind of for optometric vision therapy is we love to see people at around three
months like that because that gives us sort of that next six months to guide to
direct and it’s just it’s easier to make these changes before we get these
imbedded deficits because vision when it recovers it tends to take the path of
least resistance meaning that people embed with very inflexible vergence
ranges very tight visual postures and it’s kind of hard to break them out of
that when they’re over a year post injury that being said you absolutely
can do it but this is this is the numbers that we had so that’s what we’ll
be talking about today injury type motor vehicle accidents were 38 we had
sports-related ten and falls were eight and the delay in starting vision therapy
so they’re 15 months post injury the delay is six weeks so that’s important
about something we’re gonna talk about which is how we prescribe glasses so we
turn them many of you seen my reports talking about therapeutic glasses and
you’re probably what is he talking about so I’m gonna take us through what it is
that we’re trying to do with that essentially a therapeutic pair of
glasses is being designed to try and perform some sort of guiding action on
the visual system might be oKed prism it might be an adjustment to the lens power
it might be a tint but it’s trying to do some passive therapy on the visual
system so we generally like people to wear them for about six weeks or so
because we’ll often find their symptoms do deflate quite a bit using the glasses
and then we can jump in and start doing doing some training and therapy so what
did we measure so we measure quite a bit more than this but what we ended up
looking at was what ends up mattering in terms of visual performance
so first of all you know what we found in what’s been echoed in other studies
Goodrich had a study in 2013 showing you know and what we found too is acuity is
really a very poor predictor of the status of someone’s visual recovery it’s
it’s very rarely impacted and if it is it’s often a very subtly and a lot of
time had times has to do with an accommodative spasm or something along
the lines where they’re just not able to lock onto the target so it doesn’t end
up being we kind of know this but it doesn’t end up being all that positive
in terms of you know an overall measure visual fields are a little tricky too
because again earlier in recovery you know these people are very light
sensitive they’re very motion sensitive and we put them of course in you know
these big bright orbs and they’ve got a click and respond and sometimes I mean
the most common visual defect after post concussion syndrome is scattered visual
defect and so kind of scattered non non-conforming visual field defects so
it’s still important to do these sorts of things a lot of times you might get
better results just with a confrontation visual field
initially and then maybe kind of passing them on thereafter so if those things
kind of had a little bit less consistent findings what actually did have
consistent findings what were the things that we saw that ended up mattering or
meaning the most so one of the first things we looked at was red green near
point of convergence so we know with near point of convergence we know
generally you’re tracking the object and reporting when you see double what you
want to add to this test which I’m sure many people do is having some subtle
level of dissociation can be hugely valuable in terms of getting a more
objective response so we’ve got little slip ins we’ll put in people’s glasses
if they need near lenses or you wear the red green glasses and they’ll they’ll
track a pen light and I’ve got a video to show you how you do it I’m sure many
people are familiar but it is it does give you much more feedback and impact
the interesting though thing though is although NPC is receded that’s probably
not the most important measure and we’ll kind of go into what what may be even
more important than looking at NPC we looked at vergence facility so how many
people test virgin’s facility with the facility flippers
so by the end of this every one hand everyone’s hand is gonna go up for sure
cuz this is the fastest test that you can add to your binocular vision exam
and it is so valuable in terms of determining where someone is in their
recovery and whether they’d benefit from vision therapy the test you know if you
do it in terms of cycles per minute double it it takes 30 seconds to do and
how the person responds to it is so powerful in terms of knowing how they’re
organizing their visual space so a virgin’s facility is going to be
important and we’ll go through that of course positive fusional vergence and
negative fusional vergence those those aren’t like sexy exciting measures right
but they’re so so so valuable in terms of assessing the stability of someone’s
eye teaming you know how we think of it how much pressure can we put on your
visual system before we break down binocularity you know and we’ve got our
Morgans norms table which we reference in the study and we’ll talk about but
the more you do these tests you start to see that there’s there’s definite
repeatable objective reductions in positive and negative fusional vergence
at both distance and nearer and I’ll show you how much they generally expect
to be reduced accommodation accommodative facility you know we as we
know it’s a little age-related you you can’t test it with everyone but we still
included it because we did have a handful of people or more than half that
were within a range where you can test accommodative facility I still think
this is a really really valuable test and again how someone responds to it is
just as important as how many cycles per minute they end up doing depth
perception so I know I keep asked is how many people measure depth perception
regularly after someone’s first appointment that they’ve seen you okay
there we go so yeah that’s good so and so one of the things is that
understandably when someone first presents to our office will measure
stereopsis and we usually measure stereopsis at near because we know that
okay the binocular columns are set stereoscopic centers are our firing
we’re generally good what you’ll tend to find is stereopsis tends to be impacted
following a head injury or following concussions
and a lot of it has to do with the how that test works you know they might be
dealing with an accommodative spasm or a vergence spasm and it’s hard for them to
fuse this slightly dissociated target so we say one of what’s one of the best
screening tests for if someone needs to consider a binocular vision exam do you
feel uncomfortable in a 3d movie well we’re trying to kind of mimic that a
little bit with our testing and if you have the ability to do distant
stereopsis it can be extremely extremely important piece of the puzzle and we’ll
talk about that as well if you don’t that’s okay near stereopsis is extremely
helpful to eye tracking so we measure eye tracking with we’ve got an infrared
eye tracker where we monitor people’s eyes while they’re reading but the King
devic saccadic test is is quite well studied it’s quite well validated it’s a
three it’s a series of three you know three tracking activities where someone
reads the numbers out towards you and you make sure they stay on you know stay
on task you know it generally doesn’t take much longer than two minutes and it
gives you a really good idea on where their tracking performance is now you
don’t necessarily have their pre-injury King devic findings but you know what
someone who is 15 years and up and above should be performing like so you can
reasonably assume that if someone is 40% slower than what a 15 year old Witek
Swede be doing that there’s likely an impact in terms of saccadic tracking and
then symptoms so there’s a variety of different symptoms surveys out there we
use the convergence insufficiency symptom survey so for those who aren’t
familiar it’s 15 questions asking how people’s eyes feel when they’re reading
when they’re doing near work did they get headaches do they get discomfort did
they get tension do they get double vision it’s a really really good sort of
series of questions and you’ll see we’ve got it right on our website you do take
our screening tasks and they’ll they’ll answer the questions and it tallies them
for them and if they score above 22 and it’s likely that they have some sort of
impacted binocular vision so we included this in our in our study as well too so
this is something we use again and will ask questions beyond that so let’s go
into a little bit of the findings you know we talked a little bit of we talked
about what it is that we’re starting to look at those cohort of tests what
we actually see following in post-concussion syndrome so the first
thing we mentioned was red-green NPC under not surprisingly we do see a
receded near point of convergence but when you take the standard deviation
into account which was about six it’s not always receded you know people
generally can sometimes get the job done too closer than 10 centimeters so you
might want to watch how they’re doing it how their face are they pushing back is
there tension do they look like they’re tearing is it extremely uncomfortable
for them to do that particular activity but again generally you will see a
receipted near point of convergence but not 20 centimeters we were seeing again
13 13 centimeters as kind of being our average on the right here I have a
little video here of how we test that so we take a lot of video in our
assessments I’d say that I take assessments I take video on 50% of my
exams so you can see here she’s wearing the red green glasses we’re moving the
light in she asked her to report when she sees double so in that case it was
around 18 or 19 centimeters after she reports double you’re pulling it back
and getting a sense of where’s the recovery point when is someone able to
recover so you can see you it’s still double she’s still reporting double
still double I think she got to about 55 centimeters or so before she was able to
recover so this is someone who you know they might be able to get that first 45
minutes of computer work done but afterward they need four hours off
they’re absolutely binocular stability is is completely shot so that’s how we
would generally measure near point of convergence next what we’ll do is we’ll
look at positive and negative fusional vergence ranges so this was that these
were the statistical findings that we saw on post concussion syndrome so we
compared when you compare it to Morgan’s norms you’ll generally find P Effie’s
and n FES are at about 50% of what would be expected so their stress tolerance
their endurance their ability to hold that binocular posture while under
tension and stress that third phase of recovery we talked about with my ankle
this is where they’re still struggling and a lot of these people might be back
at work they might be back at school they might be back on the field they
might be back to living their lives but so many of them are reporting
that they do what they need to do but they have no gas left in the tank and
you can see here the stability of their eye teaming and again we’re just testing
I teaming here that’s the only system involved we’re running on about 50%
capacity so not ideal in the near centered world
that we live in nowadays the next test I said that this was this is something
that if you take anything away from today’s talk everyone should consider
getting a 12 base l-3 Basin prism facility flipper it’s it’s very very
easy to add to your eye exam I’ve got some videos of how you do it essentially
you put a 12 base out in front of someone’s eye and you ask them to fuse
it converge to make it single then you put a three base in and ask them to
diverge and make it single and you see how many cycles they should be able to
do in a minute people should be able to do about 15 cycles per minute you know
so about seven in 30 seconds what we found was this test was really really
illuminating for people who were struggling with functional visual
deficits so we were getting an average of about 2.4 cycles per minute so these
are people who are really running out of gas when their environments where they
have to do a lot of convergence divergence so what things in life do we
do that involve those sorts of things driving walking into Costco in a busy
visual scene where there’s a lot of different focal points their binocular
system is running outta gas at 15% their gas tank is 15% and their they don’t
know what the issue is a lot of these people will complain a will sight
dizziness as a big issue and you know they might call tension they might call
strain but dizziness is really really on really common in this particular group
and again part of it is you know if you start to have this unstable binocular
system your right and left eye are kind of telling you things are in slightly
different locations the world just doesn’t seem stable like it was before
so I’ll show you in these in these videos here of again what we’re what
we’re looking at so on the left here so again what we’re doing is we’re looking
at a target I use a wolf wand we’re putting we’re putting a 12 base out so
you can clear the three base in easy the 12 base out you can’t hear the video
but he’s just he says it stays it’s just saying staying double no that
isn’t getting that virgins response you ask him is there anything you can do to
make it single he really can’t do it and the more we started to do it he
started to get a little bit more uncomfortable this is a laid-back guy
though he didn’t really kind of have you know the the aversion type response that
you’ll generally see you can see on the right here when we took a look this is
kind of probably a more common response is that when you’re taking a look at
let’s see here so when you add the Virgin’s facility flipper you’ll
generally a lot of times as someone struggling with I teaming they have kind
of a you know pretty easy on the on the on the diverging head start shaking they
start pulling away they start reporting Nagy I after I do this test guy often
ask where do you feel it is it in your eyes it is in your stomach is it in your
head a lot of people feel it and feel kind of nauseous they feel unsettled
they just feel uncomfortable so it’s a test that you know proceed with caution
a little bit because you might kind of put a put a bucket beside your exam
chair but but no it’s usually 12 and 3 is usually not aggressive enough to
throw someone into any major level of symptoms but it’s enough to kind of give
you okay this person is really struggling so the general population
should be able to clear a 12 base out with relative ease and again within this
community these are people they’re 15 months post-injury
they’ve and they haven’t been sitting in a dark room for 15 months they’ve been
doing a lot of great other rehab things which we’re fortunate in Kelowna we have
so many great professionals who are working on all of the other different
aspects of concussion rehab whether it’s vestibular
whether it’s cervical whether it’s auditory whether its nutritional there’s
there’s just a host of great professionals that encourage you to
reach out to a network with what we’re seeing in this particular cohort was the
challenge was even throughout all of those things we were having very very
fragile eye flexibility that’s what I think that’s often I might communicate
it is you know your visual system has healed the some degree but like my ankle
the flexibility it’s really tight you know it would be like you know if I had
some basic rehab on my ankle and then the next level of rehab was to go run a
half marathon before I’d built up that endurance so people again if they go
into having to do heavy computer work heavy driving they just don’t have the
endurance to sustain what life asks of them so pre vision therapy here
accommodative facility this was another really illuminating one too as well
people do not perform well with accommodative facility so again what is
this it’s that flexibility of either the accommodative or the Virgen system again
we found that they’re doing about 3.1 cycles per minute as an average and so
it’s about 35% of what people would be considered average so you know I use
that term like I said flexibility and endurance as something where if you’re
seeing these types of things in the exam room
then vision therapy may make the most sense in order to get these people
moving in the right direction because as I mention there’s so many great
different ways of rehabbing yourself after a concussion vision rehab is is
very precise and it requires use of filters prisms lenses all of these
different technologies in order to get the most embedded response possible
especially if it’s been a while since the injury so again you know you can’t
test it on everyone but as we mentioned to you this is an area that will
typically find we might see some challenges so depth perception you know
I asked everyone about checking depth perception this is really really
illuminating I found so in terms of our depth perception so let’s talk about
distance stereopsis the did average distance stereopsis is still at 40 to 50
seconds of Arc what we’re finding in the post concussion population is they’re
having an average of 134 seconds of arc so about a 60% reduction in their depth
perception so one of the interesting statistics that you find with
concussions is once you’ve had one concussion you’re somewhere between 2 to
3 times more likely to have a second concussion it would stand to reason that
if your depth perception for gauging where things are in space is 60% reduced
the odds of you seeing that car coming the odds of you seeing that player
coming from the side the odds of you kind of just maybe
slipping or not seeing where something was goes goes up and so it’s really
interesting to see that again the people who get these second concussions very
commonly are not dealing with a full you know full full measures of stereopsis or
depth perception like I said 60% reduction and near stereopsis is
impacted too as well and a lot of times that could be that stability of that I
teaming you know we’re finding that they’re 50% of what would be considered
average so that stability is low sometimes you can find with lenses you
can bring that up quickly if you use even just a little bit of plus lenses or
a little bit of prism just a little bit of support we something you might want
if you’re testing near lenses you might want to test it with your stereo books
sometimes you’ll see you put a put a put a lens in front of someone and you might
see you know two times improvement in their near stereopsis it’s not that
you’ve all of a sudden you know you know you’ve changed the binocular columns
it’s that they can now perform that test more comfortably and more accurately so
again depth perception reduced there for sure I tracking so I talked about this
King devic tracking test so generally someone who’s over 15 should perform the
tests in about 50 seconds reading those three those three sets of numbers in
about 50 seconds and what we were finding in the post-concussion group was
they were taking 77 seconds on average so it’s it is you might look at that and
say well it’s only 23 24 seconds but that’s still a 35% reduction in terms of
accuracy of saccades and built up over two or three hours that’s you that’s
yielding significantly reduced performance so they use this on the
sidelines in sports a lot of times just to get a sense of whether someone’s able
to return to play some type of eye tracking and if we can get access to the
King devic you know it can be a really really helpful tool to add to your your
exam room but again we also will look subjective subjectively at saccades you
know watch the person you know looking left-to-right get some feedback on how
they’re feeling there’s a great screening test that’s done in
occupational therapy and physiotherapy called the vom
test so the vestibulo-ocular motor screening test take a look at some of
that video on YouTube and it’s a it’s getting people to do saccades and ocular
motor movements and vestibular movements and asking them about dizziness asking
them about you know nausea discomfort and rating it on a scale of one to ten
so we didn’t include that in our study because we were focusing primarily just
on vision or static vision but you definitely can take a look on youtube
and learn how to do bombs and start adding and just learning more about how
someone’s performing so symptoms I mentioned to you that we do the
convergence insufficiency symptom survey you can see here we’ve got it right on
our website take our screening test if you’re wondering hey you know one of the
nice thing will great things about you know this community is I know there’s a
lot of people who kind of will do a lot of great passive referrals where maybe
just check out this site this is for from Kairos physios off to op Tom’s what
have you we’ve added this so that people can go through the questionnaire
it’ll tally up their scores and it’ll tell them okay you’re within normal
limits or you’re outside of what would generally be considered expected but we
were finding that people were getting about 39 points so it’s 39 out of 60
with the average being at around 22 so these people are walking around with
pretty with binocular i teeming symptoms that are 56 percent greater than the
general population so again it’s it is a good test and there’s been some other
studies Alvarez and a handful of others who’ve used it in concussion assessments
and so again having a scientifically validated study is really hard to do
like this these 15 questions you know they’re well-constructed and it was I
think a three year 2.5 million dollar process to get these 15 questions
together it’s not easy to have a great questionnaire that works in a variety of
situations so there’s great other options out there feel free to add them
we do find that this does does the trick for us
so in summary so who are we looking at who are the people that we were
generally seeing as we mentioned an average of about forty two point six
years old with a range of 12 to 62 years old
the since injury as we mentioned that
average was 15 months were slowly we’ve been pulling that back slowly as I said
our average now is at around 5 months which is much better we’d really like to
be in that 3 to 4 month range to be adding some level of intervention
because it’s just easier to modify rehab when someone’s a little earlier in the
process we’re not necessarily seeing people in that first first week second
week third week fourth fourth week we’re maybe a little bit further into the
process so you know again somewhere around that 2 to 4 month mark is is a
really great time to consider if these original findings were also found i
teaming so we talked about that their how their eyes are working as a team is
about 50% of what would be considered average that was the vergence ranges
that was the virgin’s flexibility with people operating with about 50% of what
would be considered average the eye flexibility so again accommodative
vergence flexibility this was a big one they’re operating at about 20% of what
would be considered average so again these people walk into busy visual
scenes it’s no wonder they feel they have to retreat within seconds of being
there they’re basically kind of like as I mentioned the gas tank on their visual
system is being drained almost immediately instantaneously so they
avoid these situations right that’s what you do you know if my ankle wasn’t
rehabbed I would avoid running you know if your visual systems not rehab then
you avoid being in busy visual environments it’s just a natural defense
mechanism that we all go through with all systems within our body depth
perception I said this was something that we found was really interesting
therefore finding measures at about 40% of what would be considered average for
sure that has to play into the fact that as I mentioned 2 to 3 times more likely
to have a second concussion after you’ve already had your first and as and it’s a
higher incident within that first 9 to 12 months of that of your very first
concussion so people have to of course be be careful and be aware of that and
eye tracking we said we were generally finding people are tracking at about 35%
slower than what would be considered considered average and symptoms this is
a big one this is really what matters you know I mean these numbers the if all
of these numbers are we do and people are having a great time
they’re not having a problems and they’re back at work and there’s funk
they’re functioning well you know there are people who have convergence deficits
that suppress one of the eyes they’re not dealing with symptoms they’re doing
all that they need to do life is fine and those aren’t the people we
necessarily work with you know you want to find we we kind of have a philosophy
that I borrowed from another colleague that if it’s not a problem we’re not
going to make it a problem you know if it’s not a problem it’s not a problem
it’s basically but if someone’s finding these sorts of very uncomfortable
objective symptoms then I would argue that it probably is a problem so on
average as I said it’s hard to average all of these things but if we found that
their functional vision was at about forty percent of what would be
considered average and again these are people who’ve been going months
struggling at work maybe they’re not even back to work they struggling with
driving maybe they’re not even back to driving struggling having any energy at
the end of the day for their family because they’ve spent there’s so much
demands that they have to deal with just to get through the day so again as I
said we’re just looking at the visual functions we’re finding that when you
look at static visual performance we’re at about 40 percent of what would be
considered average so you know as I said we’re we’re really grateful because I
know I know within this room I we I think we’re very fortunate that we have
a very good optometric community here and what I mean by that is we get we get
a lot of referrals from optometrists and we’re very very proud of that fact I
would say you know of the referrals we get we probably get 40 percent from
optometrists which is which is somewhat unique in the vision therapy world is
the honest truth and we’re really grateful for it and I know people are
doing are doing these screenings and they’re asking questions and they’re
sending a letter or they’re sending a passive referral so I really do
appreciate it and again you know just to give you a little bit more hard evidence
on K when this is going to make a whole lot of sense these are the types of
things that you’re going to find so what do we do what do we do to manage these
sorts of things from a vision therapy sort of standpoint so the first thing
that I talked about was when someone initially comes in almost without fail
we we consider adjusting their glasses not
always but I would say in ninety ninety-five percent if someone’s
reaching a couple months post-injury then we want to think about changing
their lenses and what we’re doing when we’re when we’re prescribing glasses
therapeutically is we’re focused a little bit more on our dorsal stream
processing so our motion processing so we’ll go through kind of just some
examples of the types of things that I’m looking for but we know that within the
fibers of the optic nerve twenty percent of them had semi directly to our
superior colliculus and that’s what’s involved with directing movement that’s
what’s involved with gaze stabilization between head and eye movements so we’ve
got and a lot of those fibers are coming from our peripheral or magnocellular
stream and so what we’re trying to do is allow the visual system for lack of a
better phrase to breathe a little bit more to become more peripherally engaged
and peripherally aware so that someone can start to because once once you get
that peripheral vision integrated a little more functionally you can start
working on the eye teaming more directly so how many people have read the ghost
in my brain I’m asking bad questions I’m not gonna hit so so this is a
fascinating book we probably get about I would say 50 people come to our office a
year just because they read this book and the reason is there’s a large cohort
there’s a large set of chapters within this book that talks about therapeutic
lens prescribing and the experience of neuroscientist Clark Eliot so he had
worked with dr. Zelinsky I’m not sure if anyone’s familiar with her she works in
the Chicago area she’s been a wonderful mentor I’ve you know seen countless
hours of lectures with her but she talks a lot about how how to prescribe prism a
ioke prism how to prescribe tints how to prescribe to integrate the auditory in
the visual system it’s outside of the scope to go into all of the particular
details we’ll go in generality but suffice it to say that there’s a lot of
people when you kind of help reorganize visual space you can see some pretty
profound changes in terms of performance you know
we’ve got 1.2 million ganglion cells that you can alter in one second by
putting a lens on someone’s eyes and if you do that with art and finessin you
can really start to see some some profound changes so the types of things
that I’m doing with glasses would be different than what I would be doing if
someone hadn’t necessarily had a head injury so as I mentioned you know what
our therapeutic glasses what what am I talking about when I reference that in
in an assessment so when you look at a compensatory type correction we know
that what we’re initially trying to do it’s focus on our ventral stream our
what is it pathway so it’s in a darkroom looking down the tunnel max clarity
maximizing clarity see the signs you know see the ball see things with
precise clarity and that’s a really important way in which to measure
glasses we try and focus a little bit more on the dorsal stream and so as
you’ve seen the vast majority of people who are involved in envision therapy we
move them out of progressive lenses first of all because again even the
greatest progressive lenses still do have peripheral visual distortion which
can impact the balance center because again it’s coming down that
magnocellular stream which is feeding into that superior colliculus so we’re
trying to let that visual system breathe a little bit more a lot of times with
cylinder we know in a corrective lens you do corrective cylinder meaning that
I’ve measured minus 0.75 at axis 73 and I might adjust it a little bit but
that’s generally what I give which there’s absolutely nothing wrong with
that what you’ll find with a lot of our lens prescriptions is they look a little
simple as what we might do is because cylinder is again at an oblique axis and
it still has magnification impacts we’ll often may be oriented to 90 degrees or
180 degrees and cut it down so 75 at 73 you might become a quarter at ninety or
it might be nothing really at all that we’re going to be using throughout the
course of therapy not always but it’s something that that’s a consideration so
just so people know you know where the the logic is behind that in terms of
prism we know that generally with a correct a compensatory lens oftentimes
prism is used to compensate we very we more commonly in therapeutic
lenses use yoked prisms so one of the things that I think that this is a good
point to talk about it I mentioned to you that people are generally their
visual systems often very inflexible following a concussion and a lot of
times these people are locked into their sympathetic nervous system is on
overdrive they go into fight-or-flight very easily kind of almost like the deer
in a headlight there they’re all they’re sympathetic nervous system the autonomic
dysregulation is very common so I don’t know if you’ve ever you know had to
shoot a free-throw at the end of a sports game or something you know a
basketball game and what happens is if it’s a big big game you functionally
close off that peripheral visual field and you don’t have as many cues for
depth and what happens is if you’re locked in that posture for an extended
period of time a lot of people following concussions
start to demonstrate an ISA for ik posture at distance they tended that’s
very common to see people who are Issa for ik now one of the things about prism
that I think it’s important to to talk about is what we generally would do in a
compensatory lens is we might give a base out prism to stabilize binocularity
but prism doesn’t just move an image prism bends the world it moves the world
and it also either compresses or expands the world so Basin expands the world
base out compresses the world so I always just say you know if I’m on my
soapbox I can kind of say be very cautious about adding base out prism to
these ESO fours because what you’re often doing is embedding this closed
posture that becomes a lot harder to work out down the line so you may want
to sometimes what we might do is give a little bit less – to try and passively
stimulate divergence because again we know base out is a tricky prism – it’s
tricky prism to get away from you know it has a it’s kind of has those
addictive properties right in you know in the way that a myopic lens is – right
but what we’re doing again is it’s compressing space so just be cautious if
you’re going to use that I’m not here to tell people what to do you know everyone
here is you know great clinicians I would just say maybe be a little caught
just because you’ll see that an ISA fork posture is really common it’s actually
in the literature to that that that’s that’s not just my observations that’s
something that that is common so in terms of tints you know I know a lot of
people have seen that we very commonly use tints in our glasses and so that a
lot of times what we’re doing is we might be using a certain tint that
dampens critical flicker you know flicker sensitivity so kind of a you
know a lower wavelength like a blue or a green or something like that or we might
use this something that’s enhancing motion processing you know remember with
the Nike contacts like a yellow type lens will enhance that so we might be
doing that subjectively but we also take people through you can see me doing it
on the side something it’s called sin tonic retinoscopy which is we’re using
filters and we’re observing Retton off retinas Copic responds based on the tint
that’s being and it’s similar if you put a plus lens or a minus you kind of see
the see that I light up when there’s a when there’s a tint that’s somewhat
engaging so there’s a boat there’s a number of different tints that you can
kind of trial and work through and we found that this is is very very
beneficial for guiding our therapy process because you might see that
someone they might be wearing a certain tint in their dress pair of glasses but
when they come to see us they cycle through significantly more different
tints while they’re doing their eye tracking and we’re using retinoscopy a
lot of times to guide that so a bit of a rabbit hole to go into kind of a tint
the tint theories but you know feel free to reach out and I can direct you to
resources to learn a ton more so it’s really fascinating actually and it’s
been a huge huge huge leap beneficial addition to our practice and then as I
mentioned you know I still four years in I still don’t have an auto refractor I’m
very focused on retinoscopy that’s I want to know what lens this person can
tolerate and the best way that I can generally do that is looking more at
retinas Copic responses it’s not necessarily the lens that again as I
mentioned will get that best sort of ventral stream clarity but it’s the lens
that that visual system can tolerate so I find retinoscopy to be the most
valuable tool for that so now on to the vision therapy so again as I mentioned
in terms of what’s done in vision therapy it’s it’s a bit
as a you know that there’s there’s a wide variety of things that we go
through and I’m just gonna touch on generally what we do and then we’ll kind
of go into the results but I think that the best way to kind of pass this along
is just to tell again another little brief story so about ten years ago I
started to try and take up swimming I tried to become a swimmer like I’ve
always had good endurance like I’ve played sports and ran and done all these
sorts of things I tried to take up swimming and I was absolutely atrocious
like I had I think I got to read when I was a kid or something like you know
whatever the color is that you won’t die but you’re not gonna thrive type things
so that’s what I had I had done and so when I was trying to take up swimming
what I would find was you know I would do about two laps and I was absolutely
exhausted you know could run for thirty kilometres and swim 400 meters and I was
absolutely dead my wife on the other hand could swim 40 laps and get out of
the pool like she just did nothing absolutely nothing and so in terms of
kind of working on my swimming skills or my swimming efficiency you can’t just
jump in the pool and say we’ll just keep swimming just keep swimming you know
people are struggling with reading just keep reading just keep reading the
people are struggling with computer performance just keep working on the
computer keep working on the computer you sort of have to break vision down
into its components in the same way you break swimming down so again what I
would do is grab the flutter board work on the lower body you know get the legs
together work on the upper body focus on the path of entry focus on breathing
focus on head orientation focus on hip rotation focus on what you do it and you
get to the end in order to bounce back I’m still not a great swimmer but I at
this point you can improve significantly when you focus on each of the different
components that make up the particular task and that’s what we’re doing in
vision therapy and this is where I really have to give a huge shout out to
our team I am convinced we have we’ve got one of the best teams in the world
we’re it is unbelievable because you know not only are they very very capable
vision therapists on our team their ability to develop rapport
is incredible so people don’t do rehab or training for people they don’t
connect with that’s just that is just a fact of any type of rehab and you the
ability to connect with these people in a variety of different situations is so
impaired is so so so paramount to their performance and I just have to you know
thank them for being amazing at taking people through these cycles so the first
kind of activity we might work on is something related to central peripheral
integration you know we’ve got a variety of different things different activities
feel free of course to come by the office we happy to show show you some of
the things we do the next thing we might do is an IEEE teaming activity so a
vergence activity we might be doing a prism activity like a training prism we
might have people wearing we’ve got all the 3d training technology the big TV
screens the fancy eye tracking gadgets we’ve got all of that stuff in the
office and we might be taking them through some of that stuff that’s
related to Virgin sorai teaming then from there we might do an eye focusing
so an accomodation type activity if it’s age appropriate to do so and then we
would do an eye tracking so something related to pursuit or a cicada again
we’ve got all the fancy lights that light up and you see it kind of go and
you have to move your hand in response to it and it’s good it’s motivating
people they can see their scores improving you got variable lights it’s
it’s engaging athletes love it students love it it’s it’s generally is a lot of
fun and then we’ll do something related in some capacity to motion processing so
by motion processing it might be a Marsden ball moving or they’re tracking
letter it might be that the client is moving and the target is stationary so
we have you know we have internal programs that we’ve worked on over the
last you know seven years or so and you you you you continually build and add
more tools to what it is that you’re doing but we generally have a structure
in terms of how we’re managing these cases and then we consult on them weekly
in terms of what what we’re going to adjust or change but generally what we
find is in vision therapy will often find that you’re sequencing about 75
activities over the course of somewhere between 15 to 20 sessions
that’s generally kind of how our structure is set up in terms of vision
therapy now one of the reasons we wanted to
do this study was to figure out you know generally for vision therapy it’s it’s
often quoted somewhere between you know ten and forty sessions is kind of the
common length and we wanted to kana get a sense of what parts of vision take ten
sessions what take twenty what takes maybe a little bit longer and then from
there we can discuss it with insurance part you know insurance companies we can
discuss it with clients give them an idea of okay this is this is the reason
why the length is what it is so post vision therapy so we’ll take a look
again as I mentioned most of these people are working in average somewhere
between ten and twenty sessions so near point of convergence what we found again
this is something that absolutely is modifiable fifteen most months post
concussion it doesn’t matter you can change it and it’s one of the fastest
things to recover to Grose near point of convergence as I said was in about that
ten session mark we were starting to see that people were within what would be
considered a normal range it’s important to point out though that their symptoms
were not where they end up being if you work on the other areas of function so
it’s so important to again as I said at the start a non receded near point of
convergence is not necessarily does not necessarily mean that the person doesn’t
need to consider vision training or vision therapy so their convergence
ranges as we saw here in terms of their positive fusional and negative two
fusional vergence we saw an average about a two and a half times increase
and that was again these the PF vs and the NF es tend to take closer to around
that you know fifteen to twenty session marks and you’ll see in the study that
we break it down you know people who did ten sessions here’s where here’s fifteen
years twenty and we found that we would we’d get more consistent findings in in
closer to around that twenty sessions the P FES or the converging and
diverging at near that stability we found we saw an average of you know two
point seven times increase for converging and two times for diverging
these are again a little bit more closer to twenty sessions to get these types of
findings and as you can see you know we’ll comparison all of these are now
well within meeting Morgan’s norms these are people who are now functioning if
they came off the street I wouldn’t able to necessarily determine a
functional visual deficit and virgin’s facility I said if there’s anything
people walk away from you know I hop hop online and find a vergence facility
flipper really positive changes 2.4 cycles per minute up to 13.1 cycles per
minute so that improved it’s an 83 percent improvement in the flexibility
of focus so it helps with driving we get a lot of people back to driving it helps
with busy visual scenes we help people to be able to tolerate that type of
environment really well and a lot of that comes down to the fact that we’re
building that eye teaming flexibility and we found that when we break down the
categories of how long they’re with us closer to 20 sessions was a little more
consistent in terms of our results accommodation again we saw very profound
and positive changes in terms of accommodative performance we saw about a
71% improvement so from 3.1 cycles per minute to around ten point six cycles
per minute and we found that again we’re at around that 15 session mark you know
it’s not that we don’t see a little bit more improvements with a longer
treatment time it’s just a matter of you know are they clinically significant
improvements are they statistically significant those are the things that
that mattered to us in terms of setting out these findings and setting out the
results and depth perception so this is this is this is the one that we’re very
really proud of you know this is this this this for us is one of the reasons
why we get a lot of like I said people back to driving back to sports back to
feeling like you know they’re again you know they’re if they’re a baseball
player they’re hitting better if they are you know someone who’s driving
they’re more comfortable behind the wheel we saw really profound changes in
static depth perception you can see a distance we saw almost a 70 percent
improvement in depth perception and again somewhere around that 15 sessions
of training near depth perception or stereopsis again a 40% improvement
somewhere around that 15 that 15 sessions so again we in terms of these
these measures of stereopsis they’re not necessarily static and so you know if
there’s another tool you can add to your post concussion assessments you know
even if it’s near stereopsis that might give you some clues
to how they’re dealing with maybe an accommodative struggle or a virgin
struggle so again we saw some really positive and powerful changes and then
with eye tracking so again we saw very very solid and consistent improvements
in eye tracking a 30 almost a 30 percent improvement the average as I said for
this test is around 50 to 51 seconds so people are now tracking at age norms age
normals so they’re not having to work 30% harder to read that email or to read
that document at work they’re much more efficient in terms of how they’re using
their visual system and as I said some of that you know going back to the
swimming analogy some of that is we work on the saccades the other thing is their
peripheral vision is a little more engaged so they know where to jump to
next and the other thing is their accommodative system is a little more
accurate so the words aren’t going in and out of focus the Virgen system is
more stable so the words aren’t slightly doubling and as a result it’s easier for
them to predict where they need to move their eyes and as a result they do it
faster so that’s what we generally like I said found with with saccadic tracking
and symptoms so really this is this is the big thing really as I mentioned you
know it’s really great to fix optometric data problems but it’s much better to
fix the problems that people are dealing with in their life and in this
particular case on average as we said we saw really really really profound and
positive reduction in symptoms as we saw I said that average for that test was
you know above 22 is concerning average they were they were down 49 percent
reduced symptoms so scoring an average of about 20 on that particular test so
we were this is this is something that again this is someone who has more gas
in the tank for work they’ve got more energy towards the end of the day
they’re able to get back to work so that they can provide for their family as I
said this demographic is these people who are providing and and so I think
it’s you know reducing their symptoms has very very you know big big impact on
their lives and again just to point out again if you’re wondering up with the
questions you can take a look at our screening survey feel free to answer the
questions yourself and again if there’s someone who you’re not sure you saw a
few things that were little off say hey cuz I know within an
exam if you’ve got 20 minutes or 30 minutes you’ve got to look at so many
things I’ve got an hour and a half and I’m looking at you know this one sort of
collection of things so I sort of have time to really dive into this I’ve time
to trial lens as I talked about therapeutic glasses but I’ve got an hour
and a half we have people walking we have people catching balls we have
people writing we have certain kids cutting using different glasses like we
can really see how the lenses may be may be impacting motor performance or that
output and so again if you’re looking for a passive option feel free to direct
them to – some of the questions that we have available there so our summary you
know as I mentioned here in terms of the visual system there we found that before
vision training we found that we were seeing on average and this was our
cohort there there i teaming was that about 50% of what would be considered
average again compared to morgan’s norms post vision therapy they were operating
at what would be considered norm normal 100 percent sort of capacity eye
flexibility this was the big one 20 percent of average and following doing
vision training up to 87 percent of what would be considered average and again
that time frame is on the right these are around 20 sessions where we would
find that depth perception operating at about 40 percent of capacity up to about
90 percent of capacity somewhere around 15 sessions or so we started to see
those findings eye tracking 35% slower now what we’re noticing is again they’re
tracking on with age age normality and symptoms as I said you know we’ve got
two people who are 56 percent greater symptoms than average and after we’ve
got people who are dealing with an average amount of visual discomfort or
binocular discomfort so in summary as I mentioned we said we’re seeing we’re
seeing these people who are at about 40% of what would be considered normal in
terms of visual functional measures and after going through vision training and
vision and vision therapy we found that their visual function was closer to
around 95 percent overall which again I think it’s important to underscore
that you know as I mentioned we’re seeing people later in the game so it’s
not to say that vision therapy is the magic bullet that cures everything that
someone is dealing with we know a lot of work has been done before they make it
in to my exam chair people are doing a lot of work to stabilize their
distributor system they’re doing a lot of work on their cervical system
auditory system nutritional system lifestyle they’re working with psych all
you know there it really takes a village when we looked at the specific visual
findings however we found that this was the unique area that we’re able to add
to the rehabilitative community which again there’s a lot of different people
who are offering a lot of you know fantastic services and programs we
wanted to figure out what we do that’s unique because if you better understand
what you do that’s unique then you end up making sure that the right people are
finding you so in terms of our discussion you know we found that the
results of this analysis supported findings of previous studies and
demonstrated statistically in clinically significant improvements of measured
oculomotor functioning in patients presenting with oculomotor deficiencies
associated with post concussion syndrome and support VT as a viable treatment
option for these associated symptoms furthermore as I mentioned what we found
was presented routes results suggest longer treatment times might improve
measures measured outcomes comparable to patients receiving 10 vision therapy
sessions or less and that’s why I wanted to tease out each category there’s some
things that we did see we were able to get done in a shorter period of time but
again we maybe the maybe the the legs are working well while they’re swimming
but they don’t have that they don’t have the proper arm movement they don’t have
the right breathing pattern it’s not all coming together and what we found was
you know within the paper there’s 32 different references we found that we
had similar findings to you know the kenka Freda papers shimen work the work
of Alvarez a lot of other people who have done this type of work was again
we’re trying to add to that body of science and evidence that that is out
there for for what it is that we do so in terms of the in terms of that that’s
sort of this the science conclude these are the these are the types of
things that we hear all the time and I don’t mean to kind of just blow smoke
and say everyone walks in and just loves everything but it is a really positive
amazing environment when people make it into the it’s kind of like a refuge for
them sometimes and in this in this lady’s case you know we’ve got hundreds
of different collection of people who’ve had really positive impacts and in her
case she had mentioned again her glasses they feel like magic I had a little kind
of cheeky line there a lot of people in our therapy room kind of term them their
magic glasses and it’s kind of because they’ve put them on and it just kind of
deflates some of the pressure in tension that they might have been dealing with
for six to nine months and in this particular case as I said you know she
mentioned the vision therapy it’s not that it’s easy but it really can have
very profound impacts on someone’s performance and in life so I’m kind of a
take-home message person so I wanted to talk a little bit about the types of
things that I think are important to consider so as I said here optometrists
I feel I want us to all feel empowered to know you know I’ve been in the
rehabilitation community for a long time now and we have such unique skills to
measure visual performance and you know we just we sometimes I think that I
don’t want to say that they’re underutilized but we don’t we don’t
often know our value in terms of this binocular measurements it can be so
helpful for so many people within the rehab community for us to provide this
objective data and it’s so hard to measure it if you don’t have the types
of tools that we as optometrists do so I really feel that we’re uniquely capable
of screening for these issues we’re uniquely capable of monitoring process
and we’re uniquely capable of guiding training and recover recovery the
interesting thing is you know a comprehensive vision exam as I’ve talked
about you know it throughout this assessment it’s not yet part of the
international consensus on concussion management it’s which is which to me is
shocking but that being said you know I think that
the goal here is when people have visual issues they know to come to their
optometrist to get their eyes checked and so even if they you know aren’t
doing the full sort of comprehensive we can add some things to their assessment
that I think can can get them moving in the right direction so you know I
appreciate everyone in here for doing such as I said an amazing job and you
know being so supportive of the types of things that we’re trying to do within
the community as optometrists consider stereopsis vergence facility and ranges
so again that’s a quick 30 second test i tracking and then that symptom survey if
you consider adding those things to your to your exam even if the symptom survey
is something they fill out afterward I think it can be really helpful in terms
of at least getting people to think about how their vision might be impacted
one of the things that I’ve say you know to many of our great referral sources is
it’s it’s actually funny you know when someone comes to us and
they work with us they might be with us for five or six months and they’ve
really made some positive gains who do you think that they think most highly of
at the end of the program and I’m not just blowing smoke it’s the person that
sent them in they’re always coming in and they’re just they’re so grateful for
the fact that someone identified that this was an issue that they could work
on and so again it’s it’s it’s it’s very very common that people will express
that so again giving them tools to sort that
out or to determine what might be an issue I think can be can be very
valuable for your patient base so and when they’re finished with their program
of course we’re we’re not a primary care optometric clinic you know if a child is
doing vision therapy and the parents would like to get their eyes checked you
know we don’t we don’t offer that within our center up around 15 to 20 sessions
of vision therapy is generally sort of considered ideal Lieut you can be more
in complex cases for sure so this was again a set cohort of what we’re looking
at when you go with longer treatment times there can be other factors in play
that kind of muddy the waters of what you’re doing in terms of
so we wanted to focus on people as I mentioned who were primarily just doing
vision therapy and again we found that this was a good length of time for
working with these post-concussion case cases and as I said it takes a village
you know it takes the people who are assessing for functional visual deficits
it takes all of the hard work that’s being done by other professionals before
they get in to see us you know we can’t work on the visual system effectively if
someone has BPPV or something like that and dealing with vertigo you know or if
they have you know major cervical impingements it makes what we’re doing
significantly more challenging because again all the neurology of the eye
movements is originating around the midbrain so again back of the head and
not surprisingly people who get whiplash or hit the back of their head with a
concussion will often have more visual deficits than someone who hits any other
part of their heads so again as I said it really does take a village in terms
of in terms of managing these particular cases in summary kind of at the top
there I talked about baseball I talked about my experience and I’m back to
playing baseball but I’m not getting drafted anytime soon it doesn’t really
matter all that much it matters to my my lifestyle but it’s not really that big
of a necessity in my life computer work driving the ability to earn a living the
ability to go back to school all of these things these do matter to people
and so as I mentioned that third phase of recovery that stress tolerance that
flexibility that endurance that’s really where we as optometrists can help guide
and help train and I hope that from today you know you have a few more tools
and just some some data to look back on and reference to know if someone falls
into fitting the category of of needing to consider vision therapy

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