Course Objectives - Optometric Extension Program · Case report: MBH • A 91 years old recently retired optometrist suffered a massive stroke while attending a birthday party for

Stroke of Fortune Found in the

V.T. Room

Holly Harlow, COVTT Marilyn Brenne Heinke, OD, FAAO, FCOVD

Brenda Heinke Montecalvo, OD, FCOVD, FAAO, FCSO !

Questions: [email protected] 1 © 2015 Brenda H. Montecalvo, OD

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! When vision works well it guides and leads, when it does not it interferes. John Streff, OD, DOS, FCOVD, FAAO

2© 2015 Brenda H. Montecalvo, OD

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Optometry can give hope when other professional

care has plateaued.

3 © 2015 Brenda H. Montecalvo, OD

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August 8, 2016

Vision‘s purpose is to guide actions, growth, understanding and the quality of life. The sensory component of vision is to serve as a feedback mechanism to evaluate the adequacy of our actions. Vision problems should be explained in terms of performance. John Streff, OD, DOS, FCOVD,FAAO

© 2015 Brenda H. Montecalvo, OD

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Why Optometric Vision Therapy?• Brain Injury creates myriad visual

conditions secondary to insult

• Vision is a powerful avenue to aid in the overall rehabilitation of symptoms

• Optometry can help when other rehabilitation has been exhausted or plateaued

• Vision can have a huge impact on improving cognitive skills


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Course Objectives• Cases!• Specific considerations for Neuro-optometric Vision

Therapy Rehabilitation (NOVTR) • Visual sensory procedures for NOVTR • Visual motor procedures for NOVTR • Visual thinking procedures for NOVTR


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REHABILITATION HOPE!

Journal of Brain Injury, Grey D.S. 2000

Patients in the slow-to-recover subset of brain injury benefit from longer trials of rehabilitation, with functional recovery continuing to improve months or years after injury.


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Case report: MBH• A 91 years old recently retired

optometrist suffered a massive stroke while attending a birthday party for her granddaughter. August 9, 2015

• Initial onset of left arm numbness leading to total left paralysis and inability to speak.

• Immediate care was received at the emergency room including TPA treatment


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Physical examination• Alertness noted in emergency room after

initial treatment with persistent partial left arm and left leg paralysis.

• Significant speech impairment • Imaging indicated a massive left brain and

small right brain insult secondary to clot formation from abnormal fibrillation

• 80% recovery of initial complete paralysis was noted within a few hours

• Left neglect and speech impairment showed little signs of improvement

• These improvements were maintained until a nurse inadvertently lowered the blood pressure to a level that minimizes almost all effects of the TPA


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Visual symptoms report: MBH• No interest in reading or doing any

cognitive activities. Doesn’t notice left side. • Visual Assessment

• Minimal fixation, reduced pursuits and no ability to shift fixation for accurate saccade

• Visual neglect on left • Visual field defect: Left homonymous

hemianopsia • Blur at near • Receded near point of convergence

with intermittent exotropia • Right egocentric shift • Eye health unremarkable


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Case report: Matthew

• 2 years old suffered a stroke in utero • Left visual field defect • Mild left arm and leg paralysis • Participated in consistent comprehensive

optometric care for past 12 years


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Optometric examination• Mild hyperopic astigmatism • Left visual field defect • Visual acuity normal • Significantly poor fixation with large losses

during pursuits. Saccades difficult • Receded NPC • Constricted form fields • Eye health unremarkable


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Treatment plan

• Lens prescription • Occlusion • Syntonics • Optometric vision therapy


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Follow up plan

• Lens prescription changes as needed • Bi-nasal Occlusion for CI • Syntonics when form fields reduced • Maintenance involving visual motor eye

activities at home


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Results

• Successful “A” student • Competitive hockey player • Full resolution of visual field defect


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Discussion

• Continued optometric care was beneficial • Any relapse of initial symptoms was treated

promptly • Compliance was superior • Syntonics was repeated as needed


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Case report: BJ (RVFD)


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Case BJ


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Case BJ•15YO 2003!•Left brain aneurysm!•BVR referred!•Right VFD!•OM: no track in direction of VFD!

•AC: below normal!•7a: -4.00 sph OU!•BVA: RE & LE, 20/20!•Receded NPC

• Rx: +0.37sph .25BI over Contacts!

• Occlusion: Binasal!• Vision Therapy !• Cognition: Delayed!• Reading: Difficult!• Driving: 2004!• 2009: Began to regain

cognitive skills!• 2011: Visual Field

Defect Resolved!• 2012: College19


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Case report: Marina

• 23 years old suffered a stroke • Right visual field defect • No paralysis • Significant cognitive delays


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Results

• 4 weeks of syntonic light therapy • 2 OVT sessions • First progress evaluation • Significant measurable improvements

noticed by patient and parents


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Course Objectives• 3 Cases • Specific considerations for Neuro-optometric

Vision Therapy Rehabilitation (NOVTR)!• Visual motor procedures for NOVTR • Visual sensory procedures for NOVTR • Visual thinking procedures for NOVTR


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Recommendations For The Rehabilitation Team (See Slides 99-105)

• Rehabilitation Team!• Where to place training

materials!• Lighting!• Positioning!• Fixate first then reach!• Fixate only one target when

training mobility!• Monitor symmetrical head

and body posture when using vision for reading and viewing

• Home!• Reduced screen

activity!• Participate in more

hand/eye activities!• Encourage best

posture and good breathing!

• Set up stations of activities


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Special Considerations When Working With Patients with CVA

(See Slides 106-112)25 © 2015 Brenda H. Montecalvo, OD

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Neuroplasticity & Dendrogenesis

Neurons increase connections with other neurons through sensory stimulation, learning with complex, interesting experiences that are novel coupled with motivation.

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(See Slides 113-119)


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Pearl for NOVTR

• Large changes in weather can have a negative effect on function.

• When performance takes a step back, check all environmental factors that influence performance


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Friendship!

REHABILITATION

In a study of paid attendant care to victims of TBI, the main benefit was that of friendship to the victim.

McCluskey A. 2000


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3 Purposes of Vision

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• To see WHAT things are!– Ventral Stream: Visual Sensory!

• To see WHERE & HOW things are!– Dorsal Stream: Visual Motor!

• To see WHY & HOW things relate!– Coordinating the entire process: Visual Thinking


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Different Parts of Visual Process

Cortical

SkeletalVisceral

Visual Motor

Visual Sensory Visual Thinking

seek & holddiscriminate & define

unify & interpret


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!LEARNING THE BASIC “3’S” OF OPTOMETRIC VISION THERAPY

1. Visual Sensory 1.Eyesight: 1. Far, 2. Intermediate, 3. Near 2. Fields: 1. Central, 2. Peripheral, 3. Blind Spot 3. Fusion: 1st, 2nd, 3rd Degree Fusion

2. Visual Motor 1. Eye Movements: 1. Fixation, 2. Pursuit, 3. Saccade 2. Accommodation: 1. Posture, 2. Amplitude, 3. Flexibility 3. Vergences (+, -): 1. Posture, 2. Amplitude, 3. Flexibility

3. Visual Thinking 1. Laterality/Directionality 2. Visualization/Visual Memory 3. Orientation & Organization

1. Figure Ground & Closure 2. Association/Categorization 3. Matching/Identification/Discrimination: 1. Size, 2. Shape, 3. Space


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A MODEL FOR OVT TREATMENT1. Visual motor guides visual sensory!!!

2. Child development affects vision development

3. Visually guided integration helps orientation and organization of visual space

4. The laterality concept is a foundation for higher visual perceptual concepts

5. Orientation incorporates good posture and breathing for all activities

6. Ambient organizes focal

7. Therapy lenses and prisms will enhance visual experience

8. Ask questions instead of telling to create self discovery

9. View diagnosis as a result of a “Warped” system

10. Testing is a snapshot of the visual system; base treatment on development.


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Entire Visual Process• External: Where is the world and how do I relate? • Internal: Where am I?


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Neglect versus VFD

• Factors to consider!• Reaction time!• Area of insult!• Cognitive ability!• Fatigue!

• Rule out neglect!• Finger Extinction!• Tests for neglect

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(See Slides #-#)


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Pearl: Quick Chair-side Estimates Degree of Peripheral Visual Field


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Tests for Neglect• Cookie Jar!• Draw a clock!• Figure Drawing!• Flower Copying Test!• Line bisection!• Star Cancellation !• Navon Figures!• Gradient Neglect


Slides #120-130

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Clinical Pearl

• Pursuit in direction of visual field defect including neglect is reduced compared to other secondary directions of gaze.

• Red targets increase attention in area of neglect.


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Developing the NOR Treatment Program

• Part 1: Prescribing • Best subjective refraction • Therapeutic Performance Lenses

• Prisms: Compensatory or Therapeutic • Bi-nasal Occlusion and or filters

• Part 2: Chairside rehabilitation • Part 3: Communicate with Rehabilitation Team • Part 4: In-office program

• Syntonics • Optometric Vision Therapy Rehabilitation • Maintenance & Home Visual Experiences


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Treatment

• Lenses and Prisms • Bi-nasal Occlusion • Chair side Optometric Rehabilitation • In-office Optometric Vision Therapy

Rehabilitation (OVTR)


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OVTR• Visual Motor!

• Eye Movements!• Accommodation!• Convergence /

Divergence!• Visual Sensory!

• Eyesight!• Visual Fields!• Fusion

!

• Visual Thinking !• Orientation & Organization !• Speed and Span of

Recognition!• Visual Motor Integration!• Visual Figure Ground!• Visual Closure!• Visual Sequencing and

Memory


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Course Objectives• 3 Cases • Specific considerations for Neuro-optometric Vision

Therapy Rehabilitation (NOVTR) • Visual sensory procedures for NOVTR!• Visual motor procedures for NOVTR • Visual thinking procedures for NOVTR


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Syntonics Improves Outcomes: See references for Fatigue, Brain Injury and Blue Light!

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(See Slides #131-133)


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Achieve Best Visual Acuity

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Primary Reading Acuity


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Placing Learning Materials

• Font size

• Consider primary or secondary gaze of best visual skills

• Not in area of VFD

• Slanted or flat45


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Large Print Reading• Highlight side of defect • Simple book • Large print • Resources: Readers Digest,

Library, Bookstore • Highlight side VFD is on • Interesting topic • Builds visual thinking and

saccades


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Hemi Stim

• Simulates area of field defect

• Saccades with background stimulation


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Keystone Curved Cards• Real world depth • Describe scene • Incorporates saccades • Black/white/grey is better because more

ambient processing, less focal and/or sensory stimulus

Depth Perception


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Therapy Rehabilitation (NOVTR) • Visual sensory procedures for NOVTR • Visual motor procedures for NOVTR!• Visual thinking procedures for NOVTR


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Clinical Pearls

• Eye movements deteriorate • NPC is often receded • IXT increases with external factors affecting insult,

i.e. weather, fatigue • When “cognitively connected” patient exhibits

better NPC ability

Visual Motor


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• Eye movements • Double Pursuits and Saccades • Eye throw • Saccade into neglect • Optokinetic stimulation

Eye Movements

Oculomotor visual rehabilitation affects the visual system at early visuo-cortical levels, as well as other pathways which are involved in visual attention.


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Focus Builder

• Pursuits • Saccades • Combo • More


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Fixation

• Dot items reached for with red nail polish dot

• Maintain fixation on dot when reaching

• Teach eyes to guide reach and mobility


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Effect of oculomotor vision rehabilitation on the visual-evoked potential and visual attention in mild traumatic brain injury !

• Abnormal eye-tracking metrics improved over time toward baseline in brain-injured subjects.

• Eye tracking may help quantify the severity of ocular motility disruption associated with concussion and structural brain injury.

(See Slides 134-135)


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Double Pursuits and Saccades


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Eye Stretch• Set Up

• Place 12 targets on ceiling, walls and floor at all clock positions 1:00 – 12:00

• Procedure • Imagine watching a bug crawling

from 12:00 to 1:00 slowly, then to 2:00, 3:00 etc

• Repeat moving counterclockwise • Repeat shifting from 12:00 to 6:00,

then 3:00 to 6:00, then diagonal directions

• Materials • 12 targets


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Saccades• Set up!

• Hold 2 targets 10” apart horizontally!• Procedure!

• Quickly look back and forth between targets for 15 seconds counting how many fixations can be made.!

• Repeat 5 X record number!• Materials!

• 2 Pencils with Animal Erasers


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Optokinetic Stimulation• Kerkhoff, Keller 2006, Restorative Neurology and

Neuroscience • Helps direct attention into neglected space • Increases exploration of left space • Positive influence on spatial perception • Valler 1997: arm posiiton • Strum 2006: reactivates cortical areas

OptoDrum59 © 2015 Brenda H. Montecalvo, OD

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Orientation and Organization


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Posture• Improves visual function • Improves breathing • Allows for better hand/eye coordination


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• Localization • Asymmetry • Inability to self-correct reduces

prognoses • Varies depending on fatigue and

environment • Pinch Pursuits • Reorganizes Oculocentric Localization • Gives strong kinesthetic localization

feedback • Tries to match kinesthetic to visual

localization coordinates

Localization


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Observing Egocentric Shift During Mobility

• Egocentric shift • Horizontal X axis • Vertical Y axis • Z axis


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Observing Egocentric Shift During Mobility• Watch head and exit sign• See gait• Note head, shoulder and hip position


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Observe Mobility• Balance• Stride length• Speed• Coordination with steps• Symmetry of Body Position


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Recognize Right and Left• Flashes a picture of

a hand • Pick correct answer • Timed • Hand • Foot • Knee • Shoulder


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Yoked Prism Adaptation • Rossetti 1998, Mcintosh 2002, Frassinetti 2002, Rode

2002, Luate 2006, Sumitani 2007, Seriano 2007

• JBO 2009, 20:101-105 by Massucci

• 18 pd Base Left

• Pointing task

• Helps multi sensory integration and spatial representation

• Represents extra-personal space


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Therapy Rehabilitation (NOVTR) • Visual sensory procedures for NOVTR • Visual motor procedures for NOVTR • Visual thinking procedures for NOVTR


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Visual Thinking!

• Visual Thinking !• Orientation & Organization !• Speed and Span of Recognition!• Visual Motor Integration!• Visual Figure Ground!• Visual Closure!• Visual Sequencing and Memory


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Speed and Span of Recognition: Board Tach


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2 3 8 1 9


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Tomorrow


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The dog slept.


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The cat ran.


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E H P N A


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Dynavision, Saccadic Fixator


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Visual Motor Integration


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Walk Rail or Ball Bounce or Bean Bag Throw

• 20pd, 15pd, 10pd or 5pd!• Vertical!

• BU!• BD!

• Horizontal!• BRight!• BLleft


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The ability to visually locate and identify shapes or objects embedded in a busy visual background.

Visual Figure Ground


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Figure Ground Organization helps give meaning to what is seen. When you can’t organize what you see, it creates confusion and no meaning.


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Figure Ground Organization Decreases with Age and Brain injury.


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Strategies to Assist and Develop Figure Ground!

• Play games such as…

Hidden Picture


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Attribute blocks


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The visual closure assessment for the MVPT and the TVPS helps indicate potential for successful driving

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Visual Closure


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Split Form BoardsPut one piece of each shape in puzzle and have patient complete puzzle with remaining pieces.


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Visual Memory & Sequential Memory


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Sudoku: Large, easy, fill in some if needed

• Easiest

• Enlarge

• Fill in part of puzzle

• Visual memory

• Saccades

• Hand/eye coordination


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Room Visualization

• Visual Thinking • Room Visualization and Pointing

• Prism adaptation • Visual Memory: Parquetry Blocks


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Other Activities to Build Visual Thinking

(See Slides #136–153)


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STROKE CHANGES BRAIN METABOLISM

• Reduces brain function

• Creates body wasting

(See Slides #156-218)


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Thank You!

© 2015 Brenda H. Montecalvo, [email protected]

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Your Library

• The Ghost In My Brain

• Endless Journey

• My Stroke of Insight

• Special Needs

• Vision Rehabilitation


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Recommendations For The Rehabilitation Team

• Rehabilitation Team!• Where to place training

materials!• Lighting!• Positioning!• Fixate first then reach!• Fixate only one target when

training mobility!• Monitor symmetrical head

and body posture when using vision for reading and viewing

• Home!• Reduced Screen

Activity!• Participate in more

hand/eye activities!• Encourage best

posture and good breathing!

• Set up stations of activities


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Rehabilitation Team• Physiatrists • Occupational Therapists • Physical Therapists • Speech Therapists • Psychologists • Social Worker • Rehabilitation Facility


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Rehabilitation Team

• Primary Care Physician • Referring doctor • Caregiver • Other


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Visual Hygiene• Posture • Lighting • Visual Breaks • Eye Lubricants


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Minimize Screen Time• Inhibits neuronal growth!• Passive vs active stimulus!• Decreases tone!• Increases visual stress!• Sleep like state!• Blue light exposure!• Brain needs to heal!• Apps for visual recognition and reaction time


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Reduce Photosensitivity

• Eliminate glaring surfaces • Natural light is best • Incandescent light over

fluorescent lighting • May need a stand light for

improving contrast • Visor • Tinted lenses • Bi-nasal occlusion


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Visual Noise• Clutter is high visual noise • Solid non print background is most

desirable • Cover with a sheet if needed • Visors and or bi-nasal reduce

confusion of visual noise


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Special Considerations When Working With Patients with CVA


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Developing the NOVTR Program• Establish reasonable goals!

• Patient!• Rehabilitation team goals!

• Consider patient’s environment and ability to comply !• Communicate in writing and verbally with… !

• Rehabilitation team!• Caregivers!• Patient (Remember poor memory issues)


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An Effective NOVTR Program…1. Complies with the VISUAL DEVELOPMENT Process!2. Uses VISUAL MOTOR to guide VISUAL SENSORY!3. Has VISUALLY GUIDED Sensory Integration Activities to

Improve Orientation and Organization of Visual Space!4. Builds VISUAL MEMORY and REACTION TIME to

improve daily living activities !5. Incorporates Good POSTURE and BREATHING into all

activities!6. Works AMBIENT to FOCAL!7. Uses OCCLUSION, LENSES and PRISMS for Enhanced

Visual Experience!8. ASKS doesn’t tell how to create self discovery!9. Is based on patient GOALS, rehabilitation and remediation


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Understand the Patient • Maintain patient dignity!• Recognize intelligence!• Sensitivities!• Favorite subjects!• Be compassionate!• Talk to the patient!• Don’t use baby talk!• Don’t talk loudly unless needed


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Pearls for NOVTR

• Be sure activity provides feedback!• Keep level of complexity at appropriate level!• Increase demand slowly!• Integrate activities into daily living activities (ADL)!• Give lots of reinforcement of even very small gains

as a positive outcome.


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Pearls for NOVTR

• Engage the patient’s visual attention before beginning the procedure!

• Make NOVTR interesting and new!• Encourage patients to be more independent!• Focus on the patient’s goals!• If possible have them repeat back the

instructions to confirm understanding!• Re-evaluate treatment program frequently


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• Simplify and modify procedures and adjust the instructions

• Reposition patient and instruments as needed • Reduce over stimulation with quiet, calm

environment and less visual noise

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Keys to Successful NOVTR


112

Neuroplasticity & Dendrogenesis

Neurons increase connections with other neurons through sensory stimulation, learning with complex, interesting experiences that are novel coupled with motivation.


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Neuroplasticity provides patients with a brain that can adapt not only to changes from damage, but allows adaptation to any and all experiences and changes we may encounter.


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Dendrogenesis

• Rapid, can occur in less than 30 seconds

• In vision therapy it is the “ah ha” experience.


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Neurogenesis

• Olfactory bulb

• Hippocampus

• Neocortex

• Amigdala


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Neurogenesis• Environmental complexity stimulates

visual cortex neurogenesis: Kaplan, Trends in Neuroscience Vol 24 #10 October 2001

• Environment, motivation and interest are very important for neurogenesis: Stevens 2000

• Environment complexity, interest, motivation and reducing stress increases neurogenesis.

• Be sure OVT is interesting, stimulating, non stressful and fun.


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NeurogenesisTo change the wiring of one skill, one must engage in an activity that is unfamiliar, novel but related to the skill. Simply repeating the same activity only maintains established connections. Practice helps rewire the brain. John Ratey, MD: Users guide to the brain.


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Dendrogenesis• Occurs when NEW neurons originate from neural stem cells

• NEW neurons occur daily at any age

• Needs to be a NEW experience such as Neuro-optometric rehabilitation


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Neglect versus VFD

• Factors to consider!• Reaction time!• Area of insult!• Cognitive ability!• Fatigue!

• Rule out neglect!• Finger Extinction!• Tests for neglect


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Unilateral Spatial Inattention (Neglect)

• Unilateral Spatial Neglect !• Hemi-neglect!• Unilateral Spatial Inattention (USI)!• Visual Neglect


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• Personal Space: Affects awareness of body!• Shave one side of face!• Makeup only on one side!

• Peri-personal Space: (within arms reach)!• Eat food only on right side of plate!

• Extra Personal Space (Beyond arms reach)

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Neglect vs Hemianopsia

From Kerkhoff and Shindler Neurology and Psychiatry 2000:68


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• Reduced ability to attend to meaningful sensory stimuli presented in the affected hemi-field.!

• Geniculo-striate pathway is intact.!• With or without hemianopsia and hemiplegia.!• CVA of middle cerebral artery is most common.!• Competitive process.!• Extinction phenomenon: only happens with

simultaneous perception.!• Can occur with any combination of visual, auditory or

tactile stimuli.



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Right Versus LeftRight VFD ! ! ! ! ! ! !• Left insult!• No word recognition!• Poor cognition!• Aware of VFD!• Left egocentric shift!• Base Rt. Yoked prism

Left VFD! ! ! ! ! ! !• Right insult!• Intact word recognition!• Intact cognition!• Unaware of VFD!• Right egocentric shift!• Base Lt. yoked prism

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Visual Neglect• Ignores food on left side of plate!• Shaves right side of face!• Ignores left side of body !• Denies ignoring left space and items in left space!• Rotates head and body away from area of neglect!• Inattentiveness!• Imperception!• Unawareness!• No knowledge the space exists!• Object permanence!• Occurs with or without a VFD


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Tests for Neglect• Cookie Jar!• Draw a clock!• Figure Drawing!• Flower Copying Test!• Line bisection!• Star Cancellation !• Navon Figures!• Gradient Neglect


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Tests for Neglect

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• Cookie Jar!• Draw a clock!• Figure Drawing!• Flower Copying Test!• Line bisection!• Star Cancellation !• Navon Figures!• Gradient Neglect


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Tests for Neglect

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• Cookie Jar!• Draw a clock!• Figure Drawing!• Flower Copying Test!• Line bisection!• Star Cancellation !• Navon Figures!• Gradient Neglect


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Studies of Treatments for Neglect• Hemispatial Sunglasses!

• Arch Phys Med Rehabil. 1997 Feb;78(2):230-2.Hemispatial sunglasses: effect on unilateral spatial neglect.Arai T1, Ohi H, Sasaki H, Nobuto H, Tanaka K.!

• Prism Adaptation!• JBO 2009, 20:101-105 by Massucci: Prism Adaptation in

USI.!• Mirror Therapy!

• Neurology. 2014 Sep 9; 83(11): 1012–1017.Mirror Therapy in Unilateral Neglect After Stroke (MUST trial) A randomized controlled trial J.D. Pandian, et al


130

• Mental fatigue: A frequent symptom after brain injury. !• Patients easily become exhausted !• There is a longer recovery time.!

• Blue light therapy appears to be effective in alleviating fatigue and daytime sleepiness following brain injury.!

• Next 2 slides give reference information.

131

Randomized controlled trial of light therapy for fatigue following traumatic brain injury.!


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References for Fatigue, Brain Injury and Blue Light!

•Assessment and treatment of mental fatigue after a traumatic brain injury. Birgitta Johansson & Lars Rönnbäck. Published online: 01 Mar 2017: Pages 1047-1055 , http://dx.doi.org/10.1080/09602011.2017.1292921 !!

•Description of a multifaceted intervention program for fatigue after acquired brain injury: a pilot study J. Stubberud, Espen Edvardsen, Anne-Kristine Schanke, Anners Lerdal, Anita Kjeverud, Andreas Schillinger. Pages 1-23 Published online: 05 Jul 2017. http://dx.doi.org/10.1080/09602011.2017.1344132


132

Randomized controlled trial of light therapy for fatigue following traumatic brain injury.

The current study aimed to investigate the efficacy of 4 weeks of light therapy for fatigue in patients with TBI.!

METHODS: We undertook a randomized, placebo-controlled study of 4-week, 45 min/morning, home-based treatment with short wavelength (blue) light therapy (λmax = 465 nm, 84.8 µW/cm(2), 39.5 lux, 1.74 × 10(14) photons/cm(2)/s) compared with yellow light therapy (λmax = 574 nm, 18.5 µW/cm(2), 68 lux, 1.21 × 10(12) photons/cm(2)/s) containing less photons in the short wavelength range and a no treatment control group (n = 10 per group) in patients with TBI who self-reported fatigue and/or sleep disturbance. Assessments of fatigue and secondary outcomes (self-reported daytime sleepiness, depression, sleep quality, and sustained attention) were conducted over 10 weeks at baseline (week -2), midway through and at the end of light therapy (weeks 2 and 4), and 4 weeks following cessation of light therapy (week 8).!

RESULTS:After controlling age, gender, and baseline depression, treatment with high-intensity blue light therapy resulted in reduced fatigue and daytime sleepiness during the treatment phase, with evidence of a trend toward baseline levels 4 weeks after treatment cessation. These changes were not observed with lower-intensity yellow light therapy or no treatment control conditions. There was also no significant treatment effect observed for self-reported depression or psychomotor vigilance performance.!

CONCLUSIONS: Blue light therapy appears to be effective in alleviating fatigue and daytime sleepiness following TBI and may offer a noninvasive, safe, and nonpharmacological alternative to current treatments.


133

Naveen K. Yadav, Preethi Thiagarajan & Kenneth J. Ciuffreda. Pages 922-929 Published online: 24 Feb 2014, http://dx.doi.org/10.3109/02699052.2014.887227 !Abstract: Primary objective: The purpose of the experiment was to investigate the effect of oculomotor vision rehabilitation (OVR) on the visual-evoked potential (VEP) and visual attention in the mTBI population.!Research design and methods: Subjects (n = 7) were adults with a history of mild traumatic brain injury (mTBI). Each received 9 hours of OVR over a 6-week period. The effects of OVR on VEP amplitude and latency, the attention-related alpha band (8–13 Hz) power (µV2) and the clinical Visual Search and Attention Test (VSAT) were assessed before and after the OVR.

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Results: After the OVR, the VEP amplitude increased and its variability decreased. There was no change in VEP latency, which was normal. Alpha band power increased, as did the VSAT score, following the OVR.!Conclusions: The significant changes in most test parameters suggest that OVR affects the visual system at early visuo-cortical levels, as well as other pathways which are involved in visual attention.

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135

Other Activities to Build Visual Thinking


136

Pen/cap• Procedure!

• Place cap in patient’s hand.!• Hold Pen 10 inches in front of patient.!

• Patient looks at tip of pen and places cap on pen.!

• Don’t look back and forth!• Repeat using different locations for pen!

• Materials!• Pen with cap


137

Word Search

• Enlarge puzzle • Start with familiar words that

are easy • Hand/eye coordination • Saccades • Figure ground • Highlight yellow on left

column of puzzle


138

Solitaire: Place object on side of VFD to search and scan, strategy needed


139

Spelling• Create a list of miss spelled

words !

• Use large bold letters !

• Correct spelling words by rewriting them under the incorrect ones !

• Use a large print dictionary to find correct spelling


140

Dusting• Dust safe areas • Hand/eye coordination • Judgments beyond reach • Fixation and eye movements • Sitting or Standing • Fixate objects working around • Place important object on side

of VFD


141

Vacuuming

• Safe areas • Hand/eye coordination • Judgments beyond reach • Fixation and eye movements • Sitting or Standing • Fixate objects working around • Place important object on side of VFD


142

Balloon Toss • Begin with large filled balloon, then use balloons with reduced air to increase difficulty

• Write large letters or numbers on balloon

• Call out number or letter as taps • Tap to beat of metronome • Hit against a wall or hang from

string • Use different colors • Use Rt/Lt and Both hands, feet

and head • Hang string where it can be

tapped • Builds: Eye movements, hand/

eye coordination and reaction time


143

Ball Dribble• Both hands, right, left then

alternate

• Bounce to beat of metronome

• Builds: Reaction time, eye movements, hand/eye coordination

• Write large letters, numbers or shapes on ball

• Work from large rubber ball (easy) to basketball (medium) then small rubber ball (hard)


144

Balloon Volley• Requires 2 people or can volley against a wall.

• Volley balloon back and forth between players.

• Deflate slightly to increase difficulty

• Eye movements

• Reaction time

• Hand/eye coordination145


145

Ping Pong• Use bright yellow colored ping pong balls

• Larger paddle if needed

• Eye movements



146

Gardening

• Orchids for indoors • Watering can • Dirt • Large shallow tub • Tools


147

Measuring

• Easy to handle measuring cups • Oatmeal • Large bowl


148

Concentration

• Visualization

• Visual memory

• Hand/eye fine motor control


149

Crossword Puzzle• Simple ones

• Enlarge simple puzzle

• Familiar words

• Fill in part of each word


• Fixation

• Localization

• High light yellow on left column of puzzle


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Mathematical Problems

• Put math problems on a paper

• Use large bold numbers • Highlight side of VFD


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Radio• Talk radio

!

• Provide caregiver with possible local stations !

• Stories on radio !

• May need headphones152 © 2015 Brenda H. Montecalvo, OD

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Books on Tape• Find stories or factual information

interesting to the patient • Have a good set of headphones • Create questions about the information

listened to • May need special amplification for some • Short stories • Discussion after finished • Visualization


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Injury Changes Brain Metabolism

•Reduces brain function!•Creates body wasting


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Evidence based nutritional support for Brain Injury

•Lutein: Improves memory, fluency, cognitive skills

•Calcium: Due to increase risk of osteoporosis

•Pasture raised eggs: Protects protein synthesis

•B complex: Reduces oxidative damage

•Zinc: Reduces neuronal injury

•Blue light: Reduces fatigue

•Reduce carbohydrates: Reduces brain fog

•Flax oil, cold pressed: Reduces dryness and improves brain regeneration


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Evidence based environmental support for Brain Injury

•Air quality: Can create dryness and allergies

•Medications: Dryness, reduces cognitive function, can lead to delirium

•Hydration: Helps protein uptake, decreases dryness and headaches

•Personal hygiene: Dignity and emotional stability

•Sleep: Improves brain recovery

•Light: Sunlight improves homeostasis and absorption of vitamin D

•Light exercise: Improves circulation, better long term results. Helps memory, thinking and judgement.

•Self selected music: Improves cognition


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Nutrition and CVA

Nutritional intervention reduces brain damage post ischemic stroke.


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Brain Metabolic Alterations after Ischcemia

• Impaired protein synthesis

• Excess free radical production

• Deficiencies of minerals including zinc

!


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Nutrition is particularly important since…

• 80% of recovery of neurological impairment is within 30 days

• Within 30 days of insult patients have nutritional deficits when entering rehabilitation centers.

• !


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• Calorie-protein deficits are found 6 months post acute stroke

• Reduced plasma levels of tyrosine occurs this is the amino acid precursor of brain adrenergic neurotransmitters (epinephrine, norepinephrine, dopamine).

• !


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• It has been shown to improve functional outcomes

• Tissue adjacent to the infarct is most affected by the biochemical changes

• !


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Brain Metabolic Alterations after Ischemia

• Impaired protein synthesis

• Excess free radical production

• Deficiencies of minerals including zinc

!


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The First 30 Days

• Protein (2g/kg)

• Combined with FAT

• Minimum Carbohydrates


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Evidence for Protein and CVA

Nutrition in Clinical Practice Vol. 26, No. 3, June 2011 Low-Carbohydrate Diet Review : Shifting the Paradigm

Adele H. Hite, Valerie Goldstein Berkowitz and Keith Berkowitz Nutr Clin Pract 2011 26: 300


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Suppression of Brain Protein Synthesis

• Not due to energy failure

• Not due to intracellular ion abnormalities

• Alteration of cellular homeostasis affecting the ratio of guanosine triphosphate to guanosine diphosphate

• Lowers cellular pH before ATP decreases !


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Suppression of Brain Protein Synthesis

• Decline in amino acid incorporation

• Protein synthesis is dissociated from energy metabolism in regions of brain with focally reduced blood flow

• Blood flow rates are reduced to 80% of normal

• Dysfunction of endoplasmic reticulum suppresses protein synthesis

!


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Relevancy• Inhibition of protein synthesis

leads to cell death

• If restored before cell death, cells can repair the ischemic damage and recover function.

!


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Relevancy• Stopping protein suppression reduces

progression of the infarction zone

• This reduces neuronal destruction in the ischemic penumbra

• Protein synthesis is thought to be more important for minimizing area of insult than other energy state parameters.

!


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ProteinsCellular damage in cerebral ischemia is also partly caused by oxidative damage secondary to free radical formation and lipid peroxidation.


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ProteinsIncreased oxidative stress negatively affects a patient’s life and functional prognosis.


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STROKE CHANGES BRAIN METABOLISM

• Reduces brain function

• Creates body wasting


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You Need Fat

• Helps utilization of protein

• Improves mylination


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Poor Protein sources for CVA

• Those low in fat

• Egg whites only

• Powdered whey

• Powdered protein


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Reduce the Carbohydrates•Institutional food

•High in carbohydrates


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Best Sources for Protein


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Chickens• Free Range

• Cage Free

• Vegetarian Fed

• Pasture Raised


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Nutritional Summary• Protein: 2g/kg/day

• Fat

• B vitamins

• Zinc

• Lower Carbohydrates

!


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Protein Sources• High

• Eggs

• Tuna

• Fresh Whey

• Red Meat !

• Low

• Cheese

!

!


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Protein SourcesHow good is Ensure?


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Ensure IngredientsWater, Corn Maltodextrin, Sugar, Milk Protein Concentrate, Canola Oil, Soy Protein Isolate, Corn Oil, Pea Protein Concentrate. Less than 0.5% of the Following: Natural & Artificial Flavor, Magnesium Phosphate, Potassium Citrate, Soy Lecithin, Sodium Citrate, Potassium Chloride, Calcium Phosphate, Calcium Carbonate, Salt, Choline Chloride, Ascorbic Acid, Potassium Hydroxide, Carrageenan, Ferrous Sulfate, dl-Alpha-Tocopheryl Acetate, Zinc Sulfate, Niacinamide, Manganese Sulfate, Calcium Pantothenate, Cupric Sulfate, Vitamin A Palmitate, Thiamine Chloride Hydrochloride, Pyridoxine Hydrochloride, Riboflavin, Chromium Chloride, Folic Acid, Sodium Molybdate, Biotin, Sodium Selenate, Potassium Iodide, Phylloquinone, Vitamin D3, and Cyanocobalamin. Contains milk and soy ingredients?


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Lutein

Macular pigment optical density is related to cognitive function in older people. Rohini Vishwanathan, Alessandro Iannaccone, Tammy M. Scott, Stephen B. Kritchevsky, Barbara J. Jennings, Giovannella Carboni, Gina Forma, Suzanne Satterfield, Tamara Harris, Karen C. Johnson. Age and Ageing, Volume 43, Issue 2, 1 March 2014, Pages 271–275


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Lutein

Mol Med Rep. 2017 Oct;16(4):4235-4240. 2017 Jul 20.!Lutein protects against severe traumatic brain injury through anti‑inflammation and antioxidative effects via ICAM‑1/Nrf‑2. Tan D1, Yu X1, Chen M1, Chen J1, Xu J1.


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Lutein

Relationship of Lutein and Zeaxanthin Levels to Neurocognitive Functioning: An fMRI Study of Older Adults. J or Internatl. Neuropsychological Soc., 2016; 1 Cutter A. Lindbergh, CM Mewborn et al. !


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Lutein Plus Fat

•Lutein and other carotenoids are fat-soluble, so to optimize absorption, be sure to add a little bit of healthy fat to your meal. !

•Research shows that adding a couple of eggs, which contain both lutein and healthy fats, to your salad can increase the carotenoid absorption from the whole meal as much as nine-fold.


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CalciumEur J Neurosci. 2008 Apr; 27(7): 1659–1672.!

Traumatic brain injury causes a long-lasting calcium (Ca2+)-plateau of elevated intracellular Ca levels and altered Ca2+ homeostatic mechanisms in hippocampal neurons surviving brain injury!

David A. Sun,1 Laxmikant S. Deshpande,2 Sompong Sombati,2 Anya Baranova,3,5 Margaret S. Wilson,6 Robert J. Hamm,5 and Robert J. DeLorenzo2,3,4!


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B VitaminsB-group vitamins can mitigate oxidative damage after acute ischemic stroke. !


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ZincIschemia changes synaptic zinc release thus increasing zinc released which, aggravates neuronal injury. !


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ZincPatients with ischemic stroke were found to have a lower than recommended dietary intake of zinc. !


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ZincPatients provided with normalized zinc intake had better recovery of neurological deficits than subjects given a placebo. !!


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Your Brain Needs Fat

•Helps utilization of protein!•Improves mylination


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Your Brain Needs FatFlax oil: Cold pressed refrigerated is the easiest absorbed.


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Fatty AcidNeuroprotectin D1 (NPD1): A DHA-Derived Mediator that Protects Brain and Retina Against Cell Injury-Induced Oxidative Stress Nicolas G. Bazan, LSU Neuroscience Center and Department of Opthamology, Louisiana State University Health Sciences Center School of Medicine in New Orleans. First published: April 2005!

•The biosynthesis of oxygenated arachidonic acid messengers triggered by cerebral ischemia-reperfusion is preceded by an early and rapid phospholipase A2 !

•Activation reflected in free arachidonic and docosahexaenoic acid (DHA) accumulation. These fatty acids are released from membrane phospholipids. !

•Both fatty acids are derived from dietary essential fatty acids; however, only DHA, the omega-3 polyunsaturated fatty acyl chain, is concentrated in phospholipids of various cells of brain and retina. !

•Synaptic membranes and photoreceptors share the highest content of DHA of all cell membranes. DHA is involved in memory formation, excitable membrane function, photoreceptor cell biogenesis and function, and neuronal signaling, and has been implicated in neuroprotection.


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Neuroprotectin D1 (NPD1): A DHA-Derived Mediator that Protects Brain and Retina Against Cell Injury-Induced Oxidative Stress Nicolas G. Bazan, LSU Neuroscience Center and Department of Opthamology, Louisiana State University Health Sciences Center School of Medicine in New Orleans. First published: April 2005!!•Omega 3 fatty acid is required for retinal pigment epithelium cell (RPE) functional integrity. !

•In oxidative stress-challenged human RPE cells and rat brain undergoing ischemia-reperfusion, 10,17S-docosatriene (neuroprotectin D1, NPD1) synthesis evolves. !

•In addition, calcium ionophore A23187, IL-1β, or the supply of DHA enhances NPD1 synthesis. !

•Moreover, NPD1 bioactivity demonstrates that DHA is not only a target of lipid peroxidation, but rather is the precursor to a neuroprotective signaling response to ischemia-reperfusion.!

•This opens avenues of therapeutic exploration in stroke, neurotrauma, spinal cord injury, and neurodegenerative diseases, such as Alzheimer disease, aiming to up-regulate this novel cell-survival signaling.


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Fatty acid

Neuroprotectin D1 (NPD1): A DHA-Derived Mediator that Protects Brain and Retina Against Cell Injury-Induced Oxidative Stress Nicolas G. Bazan, LSU Neuroscience Center and Department of Opthamology, Louisiana State University Health Sciences Center School of Medicine in New Orleans. First published: April 2005


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Chocolate•Several recent studies suggest that some types of cocoa contain substances that could enhance blood flow in the brain and improve brain function. !

•Flavanoids have the ability to keep the brain healthy and prevent cognitive decline and dementia. !

•After consumption of the cocoa based liquid, it was noted that there was increased blood flow to the gray matter for two to three hours.


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Good Sources of Chocolate•Chocolove XOXOX!•Dagoba!•Endangered Species!•Green & Black’s!•Lake Champlain!•Lindt!•Newman’s Own!•Scharffen Berger!•Seeds of Change!•Trader Joe’s Fair Trade Organic!•Valrhona!•Vosges


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Evidence for ChocolateHow Dark Chocolate May Guard Against Brain Injury From Stroke!May 5, 2010 - Researchers at Johns Hopkins discovered that a compound in dark chocolate may protect the brain after a stroke by increasing cellular signals already known to shield nerve cells from damage.!Ninety minutes after feeding mice a single modest dose of epicatechin, a compound found naturally in dark chocolate, the scientists induced an ischemic stroke by essentially cutting off blood supply to the animals’ brains. They found that the animals that had preventively ingested the epicatechin suffered significantly less brain damage than the ones that had not been given the compound.


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Evidence for Chocolate•Sylvain Doré, Ph.D., associate professor of anesthesiology and critical care

medicine and pharmacology and molecular sciences at the Johns Hopkins University School of Medicine, says his study suggests that epicatechin stimulates two previously well-established pathways known to shield nerve cells in the brain from damage. When the stroke hits, the brain is ready to protect itself because these pathways — Nrf2 and heme oxygenase 1 — are activated. !

•In mice that selectively lacked activity in those pathways, the study found, epicatechin had no significant protective effect and their brain cells died after a stroke.!

•Eventually, Doré says, he hopes his research into these pathways could lead to insights into limiting acute stroke damage and possibly protecting against chronic neurological degenerative conditions, such as Alzheimer’s disease and other age-related cognitive disorders.


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Evidence for Chocolate•The epicatechin is needed to jump-start the protective pathway that is already

present within the cells. “Even a small amount may be sufficient,” Doré says.!•Not all dark chocolates are created equally, he cautions. Some have more

bioactive epicatechin than others.!•“The epicatechin found in dark chocolate is extremely sensitive to changes in

heat and light” he says. “In the process of making chocolate, you have to make sure you don’t destroy it. Only few chocolates have the active ingredient. The fact that it says ‘dark chocolate’ is not sufficient.”!

•The new study was supported by grants from the National Institutes of Health and the American Heart and Stroke Association.!

•Other Johns Hopkins researchers on the study include Zahoor A. Shah, Ph.D.; Rung-chi Li, Ph.D.; Abdullah S. Ahmad, Ph.D.; Thomas W. Kensler, Ph.D.; and Shyam Biswal, Ph.D.


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Nutritional Summary

•Lutein!•Calcium!•Protein: 2g/kg/day!•Fat!•B vitamins!•Zinc!•Lower Carbohydrates


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BEMERImproves microcirculation and promotes blood flow in the smallest blood vessels. This improves cellular performance.


201

Air Quality•Dry

•Filtered

•Air Fresheners

•Allergies increase

•Headaches

•Olfactory insult has extreme symptoms

•Flowers may affect patient allergies


202

Medications• Allergies

• Can contribute to dryness

• May affect cognitive recovery

• Can affect food intake


203

Hydration

• At least half ones weight in ounces per day

• 150 pounds/2 = 75oz/day


204

Elimination• Catheter!• Bed Pan!• Commode!• Toilet • Constipation

• UTI205 © 2015 Brenda H. Montecalvo, OD

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Skin

• Dry indicates lack of …

• Hydration

• Essential oils


206

Personal Hygiene

• Improves perception of self • Reinforces independence • Improves emotional stability


207

Sleep

• Helps brain recovery • Do rehabilitation when

rested


208

Sunlight

• 30 min./day!!

• Supplement with Syntonics


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Blue Light and Fatigue Post CVA

•The effect of blue light on post-stroke fatigue!•Debilitating fatigue is a problem that is experienced by more than 50% of stroke survivors. !

•A small study in traumatic brain injury showed that patients randomied to a 4-week, 45-minutes per day schedule of blue light therapy had lower fatigue than patients exposed to either longer wavelength (yellow) light or no light.!!

Sinclair, K. L., J. L. Ponsford, et al. (2014). "Randomized Controlled Trial of Light Therapy for Fatigue Following Traumatic Brain Injury." Neurorehabilitation and Neural Repair 28(4): 303-313.


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Blue Light and Fatigue Post CVA

The effect of blue light on post-stroke fatigue!!This project investigated whether exposure to blue light can reduce fatigue in community-dwelling stroke survivors. Participants randomized to the intervention received daily blue light exposure over 4 weeks, while controls will receive daily yellow light exposure.!!Sinclair, K. L., J. L. Ponsford, et al. (2014). "Randomized Controlled Trial of Light Therapy for Fatigue Following Traumatic Brain Injury." Neurorehabilitation and Neural Repair 28(4): 303-313.


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Exercise

Canadian researchers found that stroke patients who exercised were able to improve problems with their memory, thinking, language and judgment by close to 50% in just six months


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Exercise•It has been found that treadmill activity, forced limb movement, and other physical activities help promote brain plasticity. !

•A pattern of exercise before an injury promotes a defense against cell death. !

•It is thought that in the chronic stages after brain injury, an exercise program might reactivate mechanism of healing and thus it is recommended to keep victims as physically active as possible. !

•In a related study, recreational therapy was found to improve rehabilitation.


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Exercise

Canadian researchers found that stroke patients who exercised were able to improve problems with their memory, thinking, language and judgment by close to 50 percent in just six months


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Auditory• Teppo et al Brain 2008

• Reported improved cognitive recovery after listening to self selected music

• Improved mood215 © 2015 Brenda H. Montecalvo, OD

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Herbal Remedies

•Careful with HERBAL REMEDIES!•The use of herbal supplements is common in the U.S. However, following a brain injury, remedies such as St. Johns Wort and Ginko Biloba, SHOULD BE AVOIDED. !

•Studies show that they may induce mania in TBI patients. Spinella M., 2002


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Documents

Course Objectives - Optometric Extension Program · Case report: MBH • A 91 years old recently retired optometrist suffered a massive stroke while attending a birthday party for