Vision Therapy Interventions to Support Occupational Performance for People With Traumatic Brain Injury With Visual Symptoms (June 2013–October 2020)

Abstract

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association’s Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings from the systematic review on the effectiveness of interventions that address visual impairments and visual perception to improve occupational performance for adults with traumatic brain injury.

Full Systematic Review Question

This systematic review addressed the question “What is the evidence for the effectiveness of interventions that address visual impairments and visual perception to improve occupational performance for people with traumatic brain injury (TBI)?”

Current Theme Reported

The main theme of the studies included in this systematic review brief is vision therapy interventions.

Clinical Scenario

Traumatic brain injury (TBI) can have a significant impact on the visual system leading to deficits in visual field, visual acuity, oculomotor skills, and visual processing abilities (Cockerham et al., 2009), with estimates as high as 90% of all individuals with TBI experiencing visual consequences (Jacobson & Marcus, 2011). Visual and visual perceptual deficits as a result of TBI can significantly impact participation in meaningful everyday activities (Greenwald et al., 2012; Kerkhoff, 2000). More specifically, oculomotor impairments (e.g., accommodative or convergence insufficiency, eye movement dysfunction, and cranial nerve palsy) have been found to lead to problems in reading, difficulties engaging in meaningful daily activities, and overall reduced quality of life (Barnett & Singman, 2015; Armstrong, 2018). Vision therapy refers to a structured form of visual and visual motor exercises (e.g., scanning, tracking, eye teaming, and Brock String) determined in collaboration with an eye care specialist (Berger et al., 2016). Occupational therapy practitioners can integrate these preparatory activities into progressively more challenging functional activities to support occupational performance.

Summary of Key Findings

Nine articles representing four studies were included in the review for vision therapy interventions (Table 1). The levels of evidence used in this review are from Oxford Centre for Evidence-Based Medicine (2009).

Table 1.

Evidence Table for Vision Therapy Interventions

Author/Level of Evidence	Intervention	Statistically Significant Improvement From Intervention
Two Level 2B studies, one reported in 7 articles, and two Level 3B studies implemented vision therapy to remediate oculomotor signs and symptoms in people with TBI. Moderate strength of evidence supports the effectiveness of this therapy.
Berryman et al. (2020) Level 2B—Small feasibility RCT Setting Inpatient rehabilitation Country USA	Population Adults with TBI with oculomotor impairment, in an inpatient rehabilitation program >6 wk, N = 20 Intervention Six eye exercises (eye stretches, tracking, gaze stabilization, spatial localization, saccades, and vergence) completed by intervention group, with five completed during each treatment session. Per treatment session, the control group had to perform 5 min of reading and participate in at least one of the following activities that integrate oculomotor skills: visual–motor, scanning, visual cognition, and reading. Delivery Method Individual Dose 30 min/day, 5 days/wk for 4 wk	Not reported
Thiagarajan & Ciuffreda (2013, 2014a, 2014b, 2014c) Thiagarajan, Ciuffreda, Capo-Apone et al., 2014 Thiagarajan & Ciuffreda (2015) Level 2B Setting Laboratory Country USA	Population Adults with mTBI and near vision symptoms, mean age 29; N = 12 Intervention OMT was performed with constant verbal and visual feedback, motivation, repetition, and active participation of the subject and consisted of an oculomotor component (version, vergence, and accommodation) for 45 min of training and 15 min of rest. A placebo training and binocular and monocular plano-powered loose prism and prism flippers and/or monocular vertical prism flippers were used as the placebo training analog to OMT. Delivery Method Individual Dose Two phases over 15 wk; each phase consisted of two 1-hr sessions/wk for 6 wk. Phases were separated by 1 wk with a measurement phase 1 wk before phase 1 and after phase 2.	-Vergence (convergence and divergence) (2014c), accommodation (2014b), and saccadic eye movement (2014a). -Saccade ratio, sequential saccadic tracking (2014a). -CISS total score, near vision-related symptoms (2013, 2014b). -VSAT percentile, visual attention (2013, 2014b). -Follow-up study results: CISS scores, symptoms.
Scheiman et al. (2017) Level 3B Setting Outpatient clinic Country USA	Population Adolescents and young adults (mean age 22.2) with concussion-related symptomatic convergence insufficiency, 2–24 mo postconcussion, N = 5 Intervention OBVT with home reinforcement that is tracked using a home-based therapy log completed by participant Delivery Method Individual Dose Three conditions; 60-min office visit with 45 min of therapy time and 15 min of practice at home, 5×/wk for 12–20 sessions	CISS scores NPC break, positive fusional vergence, and vergence facility between pre-OBVT and post-OBVT
Yadav et al. (2014) Level 3B Setting Laboratory Country USA	Population Adults with mTBI, 1–6 yr post injury, N = 7 Intervention OVR that included training of three oculomotor systems (version, vergence, and accommodation) with an embedded and indirect visual attentional training component alternating between eyes open and eyes closed; administered by an optometrist 2×/wk for 6 wk for a total of 9 hr (3 hr for each oculomotor system); two test conditions were used to measure VEP amplitude and latency to modulate visual attention; Test Condition 1: “Eyes Open”—all subjects fixated a small target as they gazed at the checkerboard visual stimulus. Test Condition 2: “Eyes Closed”—all subjects instructed to close their eyes, relax, “clear their mind” for 60 s before starting the recording; advised that they imagine “gazing” straight ahead where the rotating fixation target was previously presented to maintain steady gaze. Delivery Method Individual Dose 2×/wk for 6 wk	VSAT scores Mean VEP amplitude

The levels of evidence used in this review are from Oxford Centre for Evidence-Based Medicine (2009). Note. CISS = Convergence Insufficiency Symptoms Survey; mTBI = mild traumatic brain injury; NPC = near point of convergence; OBVT = office-based vision therapy; OMT = oculomotor training; OVR = oculomotor vision rehabilitation; RCT = randomized clinical trial; TBI = traumatic brain injury; VEP = visual-evoked potential; VSAT = Visual Search and Attention Test.

Bottom Line for Occupational Therapy Practice

The systematic review provides moderate strength of evidence from 2 Level 2B studies and 2 Level 3B studies that supports the use of vision therapy to remediate oculomotor signs and symptoms in people with TBI (Berryman et al., 2020; Scheiman et al., 2017; Thiagarajan & Ciuffreda, 2013, 2014a, 2014b, 2014c; Thiagarajan, Ciuffreda, Capo-Apone et al., 2014; Thiagarajan & Ciuffreda, 2015; Yadav et al., 2014). Occupational therapy practitioners should consult with neuro- optometry/ophthalmology on a case-by-case basis to consider the use of vision therapy to manage/resolve oculomotor signs and symptoms in adults with TBI. The intensity and duration of vision therapy should be prescribed by the consulting neuro-optometrist/ophthalmologist in consideration of the impact on the visual system and the client’s quality of life. Occupational therapy practitioners can integrate vision therapy in the context of dynamic function-oriented activities in conjunction with the prescribing provider to maximize client outcomes. Additional research is needed to support the effects of vision therapy interventions as a means of symptom management that impacts occupational performance and participation for individuals living with TBI.