Vestibulo-Ocular Interventions to Support Occupational Performance for People With Traumatic Brain Injury With Visual Symptoms (June 2013

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 vestibulo-ocular 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 vestibulo-ocular 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 people 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, vestibulo-ocular dysfunction can have significant impact on occupational performance as a result of dizziness, blurred vision, challenges with balance, and nausea (Wallace & Lifshitz, 2016).

Summary of Key Findings

Four articles representing 3 studies were included in the review related to vestibulo-ocular 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 Vestibulo-Ocular Interventions to Support Occupational Performance

Author/Level of Evidence	Intervention	Statistically Significant Improvement From Intervention
Three Level 3B studies and one follow-up study implemented vestibular interventions to minimize the impact of oculomotor disturbances on occupational performance in people living with TBI. Low strength of evidence supports the effectiveness of this therapy.
Adams & Moore (2017) 3B—Pre-Post test design Setting Home based Country USA	Population Adults with postconcussive dizziness and debility, N = 6 Intervention Multimodal rehabilitation program that consisted of vestibular rehabilitation and a combination of exercise, vision therapy, physical therapy, neuropsychology, and psychotherapy. Vestibular rehabilitation included gaze stabilization, gait and sensory organization and balance. Exercises began in simple stable environments and progressed to complex and dynamic environments. Delivery Method Individual, supervised home program Dose Varied by intervention from 10 min daily to 30 min 3–5 times/day for a period of 6 mo	This intervention used RPQ (King et al., 1995) and DHI (Jacobson & Newman, 1990). Statistically significant differences were found in the RPQ-3 (p = 0026) and RPQ-13 (p = .037) and DHI (p = .033) at 6-mo posttreatment.
Carrick et al. (2019) 3B—Retrospective analysis Setting Outpatient therapy Country USA	Population Adults with postconcussive syndrome (sports concussion) and mental health concerns (depression), >9 mo postconcussion, N = 6 Intervention Primary treatment: gaze stabilization exercise with coordinated HEVM at positions and speed associated with a decompensation of head and eye movements. Delivery Method Individual Dose 5×/day with minimum rest periods of 1.5 hr between sessions for 5 days for primary treatment	Saccadic metrics
Kontos et al. (2018) 3B—Pre/Post single group Secondary follow-up analysis-dose: Galey et al. (2020) 3B—Pre/Post single group Setting Outpatient therapy Country USA	Population Adults with chronic, intractable, mTBI (TEAM-TBI), N = 26 Intervention Progressive, targeted, active interventions that included: behavioral, vestibular, vision and exertion. Interventions were matched to the participant’s clinical profile. Interventions included: behavioral interventions (prescribed reading and/or screen usage) to home-based vision exercises: convergence (i.e., Brock strings and pencil pushups); saccade and pursuit exercises; or computerized home vision program. Delivery Method Individual and remote monitoring via phone and iPad Dose Not reported, assessed 6 mo post intervention/treatment	The intervention groups showed improved symptoms, verbal memory, smooth pursuits, horizontal vestibular ocular reflex, visual motion sensitivity, convergence distance, activity-specific balance confidence and (2020) visual oculomotor vision (vestibular and oculomotor symptoms) (Kontos et al., 2018). Follow up Assessing the rate of compliance in taking part in therapy, they found high compliance (vs. low or moderate) with prescribed exertion/vestibular rehabilitation therapies enhanced clinical outcomes (Galey et al., 2020).

The levels of evidence used in this review are from Oxford Centre for Evidence-Based Medicine (2009). Note. DHI = Dizziness Handicap Inventory; HEVM = head-eye vestibular motion; mTBI = mild traumatic brain injury; RPQ = Rivermead Post-Concussion Symptoms Questionnaire.

Bottom Line for Occupational Therapy Practice

The systematic review provides moderate level of evidence to support the use of vestibulo-ocular interventions to minimize the visual symptoms associated with vestibular dysfunction and low strength of evidence to support the use of vestibulo-ocular interventions to improve occupational performance in people living with TBI. Three Level 3B studies support the use of vestibulo-ocular interventions as a preparatory method to minimize oculomotor symptoms in people with visual impairments post TBI (Adams & Moore, 2017; Carrick et al., 2019; Galey et al., 2020; Kontos et al., 2018). The use of vestibulo-ocular interventions may facilitate occupational engagement in occupations by reducing the symptom burden (e.g., dizziness and oculomotor symptoms) caused by TBI (Adams & Moore, 2017; Carrick et al., 2019; Galey et al., 2020; Kontos et al., 2018). Occupational therapy practitioners should incorporate gaze stabilization, sensory organization, and static/dynamic balance exercises into rehabilitation for adults with TBI on a case-by-case basis to manage/resolve visual symptoms. More research is needed to demonstrate the impact of vestibulo-ocular rehabilitation on functional-oriented outcomes (i.e., activities of daily living and Berg Balance Scale).

Footnotes

*

Indicates articles included in the brief systematic review.

References

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