VISUAL PERCEPTUAL DEFICITS AFTER BRAIN INJURY CANDICE ELAM

VISUAL PERCEPTUAL DEFICITS AFTER BRAIN INJURY CANDICE ELAM RICE, OD, FAAO LEXINGTON VAMC

OBJECTIVES • REVIEW VISUAL INFORMATION PROCESSING • TYPES OF DEFICITS • EVALUATION • MANAGEMENT

LGN • RELAY CENTER FROM RETINA TO PRIMARY VISUAL CORTEX • MAGNOCELLULAR LAYERS • INPUT FROM RODS • CELLS SENSITIVE TO MOVEMENT • PARVOCELLULAR LAYERS • INPUT FROM CONES • CELLS SENSITIVE TO COLOR CONTRAST • KONICELLULAR CELLS • INPUT FROM SHORT-WAVELENGTH CONES

STRIATE CORTEX • CEREBRAL CORTEX – WHERE VISUAL INFORMATION IS ORGANIZED AND INTEGRATED WITH MEMORY AND OTHER SENSES TO PRODUCE VISUAL PERCEPTION • STRIATE CORTEX – PRIMARY TARGET FOR PROJECTIONS FROM THE LGN • LOCATED IN THE OCCIPITAL LOBE

EXTRASTRIATE CORTEX • V 2 – CELLS THAT RESPOND TO ALL MAJOR VISUAL MODALITIES • INVOLVED IN EARLY PERCEPTION, CELLS RESPOND TO COLOR AND FORM • V 3 – MOTION, SHAPE OF OBJECTS IN MOTION, DEPTH PERCEPTION

EXTRASTRIATE CORTEX • V 4 – COLOR PERCEPTION, SIZE ESTIMATION, LINE ORIENTATION • V 5 (MIDDLE TEMPORAL CORTEX) – MOTION DETECTION • V 6 – THOUGHT TO BE INVOLVED IN SELF-MOTION, 3 D FEATURES, TARGET SELECTION, VISUAL SEARCH

EXTRASTRIATE CORTEX • V 8 – COLOR PERCEPTION • INFEROTEMPORAL CORTEX (IT) – CELLS RESPOND TO FACES – FORM PERCEPTION

• MAGNO – DORSAL – “WHERE” • MOVEMENT • LOW SPATIAL FREQUENCIES • PARVO – VENTRAL – “WHAT” • COLOR DISCRIMINATION • VISUAL ACUITY

VISUAL PERCEPTION DEFICITS • INFORMATION PROCESSING SPEED • MEMORY DEFICITS • SPATIAL DEFICITS • AGNOSIAS

INFORMATION PROCESSING • REGISTERING INCOMING INFORMATION • COGNITIVE PROCESSING OF MATERIAL • OUTPUT

SPEED OF INFORMATION PROCESSING • SLOWED IN PATIENTS THAT HAVE HAD ABI, TBI, SEVERAL NEUROLOGICAL DISEASES AND NORMAL AGING • RELATED TO DIFFUSE AXONAL INJURY • SLOWED PROCESSING SPEED CAN SPAN SEVERAL DECADES • TBI PATIENTS CAN IMPROVE PERFORMANCE QUALITY BY SLOWING DOWN TEST SPEED

INFORMATION PROCESSING • REACTION TIME TESTS – EVALUATE SPEED OF INFORMATION PROCESSING • TBI CAUSES • SLOWER INFORMATION PROCESSING • DEFICITS IN DIVIDED ATTENTION • IMPAIRMENT OF FOCUSED ATTENTION • INCONSISTENCY OF PERFORMANCE

MEMORY • BEING ABLE TO REMEMBER VISUAL PATTERNS AND SPATIAL RELATIONSHIPS IS IMPORTANT TO COMPLETE IADLS LIKE FINDING YOUR WAY AROUND A NEW ENVIRONMENT OR REMEMBERING WHERE YOU PUT AN OBJECT • WORKING MEMORY – ABILITY TO HOLD INFORMATION IN YOUR MIND OVER SHORT PERIODS OF TIME • NEEDED TO REMEMBER NEW INFORMATION, FOLLOW DIRECTIONS, FOR COMPLEX REASONING

MEMORY DEFICITS • MEMORY DEFICITS DUE TO TBI OCCUR IN 69 -80% • MORE SEVERE INJURIES (DETERMINED BY GLASGOW COMA SCALE) INCREASE THE DEGREE AND PERSISTENCE OF MEMORY DEFICITS • AFFECTS THE ENCODING AND RETRIEVAL OF VERBAL AND VISUAL MATERIALS

SPATIAL PROCESSING • VISUO-SPATIAL SKILLS ARE NEEDED TO INTERACT WITH AND ORGANIZE YOUR ENVIRONMENT • • Figure-ground discrimination Visual closure Form perception Spatial orientation • • Right-left discrimination Spatial manipulation Analysis of visual information Visualization

PERCEPTUAL ORGANIZATION • PERCEPTUAL ORGANIZATION – INDIVIDUAL COMPONENTS OF A VISUAL SCENE ARE RESOLVED INTO A SERIES OF UNIFIED FORMS • HOW ONE ORGANIZES STIMULI • FIGURE-GROUND

SPATIAL DEFICITS • PERCEPTUAL ORGANIZATION OCCURS EARLY IN VISUAL PROCESSING • IMPAIRMENT DEGRADES PERFORMANCE OF HIGH-ORDER VISUAL PROCESSING (IDENTIFICATION OF COMMON OBJECTS AND FAMILIAR FACES) AND VISUAL SHORTTERM MEMORY, VISUAL SEARCH AND SELECTIVE ATTENTION

VISUAL AGNOSIAS • EXTRASTRIATE LESIONS CAN CREATE THE INABILITY TO RECOGNIZE OBJECTS • PROSOPAGNOSIA (INABILITY TO RECOGNIZE FACES) • COLOR AGNOSIA DIFFICULTY ASSOCIATING COLORS WITH OBJECTS) • COLOR ANOMIA (INABILITY TO NAME COLORS) • VISUAL SPATIAL AGNOSIA (DIFFICULTY WITH STEREOSCOPIC VISION & TOPOGRAPHY) • AKINETOPSIA (DIFFICULTY WITH MOTION PERCEPTION) • VISUAL NEGLECT (INABILITY TO ATTEND OR ORIENT TO THE CONTRALATERAL SPACE)

ASSESSMENT FOR VISUAL PERCEPTION DEFICITS • FORMAL STANDARDIZED TESTING VERSUS INFORMAL OBSERVATIONAL ASSESSMENT • HELPS DETERMINE MANAGEMENT STRATEGIES • BASELINE MEASUREMENTS • PLANNING THERAPY • DETERMINING NEED FOR REFERRAL TO OTHER PROFESSIONALS

TEST OF VISUAL PERCEPTUAL SKILLS (TVPS) • MOTOR-FREE TEST OF VISUAL PERCEPTION • 7 SUBTESTS • 2 EXAMPLE ITEMS AND 16 TEST ITEMS IN ORDER OF INCREASING DIFFICULTY • DO NOT GIVE FEEDBACK DURING ADMINISTRATION • STOP WHEN 3 CONSECUTIVE INCORRECT ANSWERS • TEST AGE UP TO 18 YO

TEST OF VISUAL PERCEPTUAL SKILLS (TVPS) • VISUAL DISCRIMINATION (WHICH IS THE SAME? ) • VISUAL MEMORY (REVERSALS) • VISUAL SPATIAL RELATIONS (WHICH IS DIFFERENT? ) • VISUAL FORM CONSTANCY (DIFFERENT FONTS) • VISUAL SEQUENTIAL MEMORY (COPYING, SPELLING) • VISUAL FIGURE GROUND (FIND A SHAPE HIDDEN IN PICTURES, WHERE’S WALDO? ) • VISUAL CLOSURE (IF THE DESIGN WAS COMPLETED AND LINES WERE NOT MOVED AROUND, WHICH ONE WOULD LOOK EXACTLY LIKE THE ONE AT THE TOP? READING FLUENCY)

DEVELOPMENTAL TEST OF VISUAL-MOTOR INTEGRATION • MEASURES ABILITY TO INTEGRATE BOTH VISUAL INFORMATION AND MOTOR PROFICIENCY (EYE-HAND COORDINATION) • STOP WHEN 3 CONSECUTIVE WRONG ANSWERS

GETMAN-HENDERSON-MARCUS TEST OF VISUAL RECALL • TESTS MEMORY SKILL AND THE PROCESSES OF VISUALIZATION • DESIGNED FOR ALL AGES • 9 VISUAL RECALL TEST CARDS • CARDS INCREASE IN COMPLEXITY

AUDITORY VISUAL INTEGRATION TEST (AVIT) • AUDITORY-VISUAL PATTERN MATCHING TASK • EXAMINER TAPS OUT AN AUDITORY PATTERN, PATIENT MATCHES IT TO PRINTED DOT PATTERNS • 20 TEST CARDS

USEFUL FIELD OF VIEW • MEASURES SPEED OF VISUAL PROCESSING • PREDICTS DRIVING ABILITY AND CRASH RISK

INFORMAL ASSESSMENT • INDUCTIVE REASONING STRATEGIES • NO STANDARDIZED MECHANISMS • SHOULD RELY ON A BINARY DECISION PROCESS

OTHER PERCEPTUAL TESTS FOR ABI • SPATIAL RELATIONS/PERCEPTUAL ORGANIZATION • HOOPER VISUAL ORGANIZATION (WPS) • SOUTHERN CALIFORNIA TEST OF VISUAL FIGURE-GROUND (WPS) • DTLA-4 SYMBOLIC RELATIONS • MINNESOTA SPATIAL RELATIONS TEST

OTHER PERCEPTUAL TESTS FOR ABI • SPEED OF INFORMATION PROCESSING • SYMBOL DITIS MODALITIES TEST • RAPID AUTOMATIZED NAMING • GROOVED PEGBOARD • TACHISTOSCOPE

OTHER PERCEPTUAL TESTS FOR ABI • MEMORY • DTLA-4 DESIGN SEQUENCES • TOMAL-2 MEMORY FOR LOCATION • TOMAL-2 VISUAL SEQUENTIAL MEMORY • TOMAL-2 MANUAL IMITATION • WRAML-2 SYMBOLIC WORKING MEMORY

MANAGEMENT OF VISUAL PERCEPTUAL DEFICITS • OPTOMETRIC REHABILITATION THERAPY • GENERAL TREATMENT STRATEGY • OFFICE THERAPY • HOME THERAPY • SEQUENCE OF TREATMENT • PROCEDURE EXAMPLES • OCCUPATIONAL VISUAL-PERCEPTUAL THERAPY

OPTOMETRIC VISION REHABILITATION • TREATMENT STRATEGY • CORRECT REFRACTIVE ERROR • TREAT VISUAL EFFICIENCY ANOMALIES (VERGENCE, ACCOMMODATION) • TREAT RESIDUAL VISUAL INFORMATION PROCESSING ANOMALIES

OPTOMETRIC VISION REHABILITATION • TEACH HOW TO SOLVE THE PROBLEM RATHER THAN POINTING OUT CORRECT ANSWER • POSITIVE REINFORCEMENT • DEVELOP AUTOMATICITY – INCREASE SPEED, ACCURACY, STAMINA

OFFICE THERAPY • DOCUMENT HOME THERAPY MINUTES/DAY • DOCUMENT IMPROVEMENT OF SYMPTOMS, DIFFICULTY OF TECHNIQUES, SUCCESS WITH TECHNIQUES; REVIEW HOME THERAPY TECHNIQUES • OFFICE THERAPY • 4 TO 6 TECHNIQUES PER SESSION • RETEST AFTER 5 -6 SESSIONS

HOME THERAPY • TO ESTABLISH CONDITIONED REFLEXES • REGULAR PRACTICING PERIODS INCREASE REFLEXIVE NATURE/AUTOMATICITY • REDUCES NUMBER OF OFFICE VISITS • PREVENTS REGRESSION BETWEEN OFFICE VISITS • MAINTAINS PATIENT INTEREST • INCREASES OVERALL COMPLIANCE AND SUCCESS • 15 -30 MINUTES PER DAY

SEQUENCE OF TREATMENT • VISUAL SPATIAL SKILLS • BILATERAL INTEGRATION, LATERALITY, DIRECTIONALITY • VISUAL ANALYSIS SKILLS • VISUAL DISCRIMINATION, FIGURE GROUND, VISUAL CLOSURE, VISUAL MEMORY, VISUALIZATION • VISUAL MOTOR SKILLS • GENERAL EYE-HAND COORDINATION, VISUAL-MOTOR ERGONOMICS, FINE-MOTOR CONTROL

PROCEDURE EXAMPLES • DIRECTIONAL MAZES – PATIENT TELLS YOU WHICH WAY TO GO • LETTER REVERSALS – PATIENT CIRCLES REVERSED LETTERS

PROCEDURE EXAMPLES • PARQUETRY BLOCKS – VISUAL DISCRIMINATION, VISUAL SPATIAL RELATIONS, VISUAL CLOSURE, CAN DO VISUAL MEMORY, VISUAL SEQUENTIAL MEMORY, VISUALIZATION

PROCEDURE EXAMPLES • MICHIGAN TRACKING – FIGURE-GROUND, OCULOMOTOR, REVERSALS, VISUAL MEMORY • WHERE’S WALDO – FIGURE-GROUND

PROCEDURE EXAMPLES • TACHISTOSCOPE – VISUAL MEMORY, VISUAL SEQUENTIAL MEMORY • WAYNE SACCADIC FIXATOR – SPORTS VISION

COMPUTER PERCEPTUAL THERAPY

OCCUPATIONAL VISUAL-PERCEPTUAL THERAPY • OCCUPATIONAL THERAPISTS – SCREEN INPATIENT ABI/TBI PATIENTS FOR VISUAL-PERCEPTUAL DISORDERS • MOST OCCUPATIONAL THERAPISTS HAVE TRAINING IN VISUAL-MOTOR INTEGRATION (ESPECIALLY MOTOR ASPECTS). SOME HAVE TRAINING IN VISUAL PERCEPTION.

SUMMARY • PERCEPTION IS ESSENTIAL TO ACQUIRING KNOWLEDGE • MOTIVATION IS KEY FOR REHABILITATION THERAPY • REHABILITATION OF VP DEFICITS HELPS PATIENTS UNDERSTAND THEIR ENVIRONMENT

REFERENCES • ADVANCED VISION AND LEARNING ELECTIVE, DR. KATHY WEISE, UABSO 2009 • ASHLEY, MARK J. TRAUMATIC BRAIN INJURY, REHABILITATION, TREATMENT, AND CASE MANAGEMENT. THIRD EDITION. 2010 TAYLOR AND FRANCIS GROUP • JEFFRIES, AM, ET AL. “MAPPING THE PRIMATE LATERAL GENICULATE NUCLEUS: A REVIEW OF EXPERIMENTS AND METHODS, ” JOURNAL OF PHYSIOLOGY – PARIS 108 (2014): 3 -10. • SCHWARTZ, STEVEN H. VISUAL PERCEPTION, A CLINICAL ORIENTATION THIRD EDITION. 2004 MCGRAW-HILL

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