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Posted on 09-17-2013

Concussion, Brain Injury and the Visual Process

Originally posted on November 28th, 2012

Most adults are probably familiar with the topics of acquired brain injury and post-concussion syndrome these days.  We probably either know someone who has suffered a brain injury such as a stroke, or sustained a head injury in a car accident or fall, or we have heard about a professional athlete or student athlete who has had a concussion.  Add to this list the all-too-quickly growing number of those who have served in the military and sustained brain injuries as a result.

One of the most important things that has changed about these head injuries is the level of public and professional awareness of them and their consequences.  In the past, deficits resulting from acquired brain injuries were poorly understood, often leaving the person without appropriate treatment and without them, their families, friends, teachers and employers understanding why this person suddenly began behaving and/or functioning differently.  Many brain injuries result from a type of head trauma known as closed head injury where the skull is not fractured.  The problem with closed head injury is the perception that since there is no obvious physical damage it is easy to assume the person is essentially undamaged in other ways.  However, the visual (and other) disturbances resulting from a closed head injury can be just as devastating to a person’s ability to live the life they lived prior to the injury.

I think this new level of understanding is particularly important with young people and concussions.  I’m sure that in the past many athletes, including young ones, suffered concussions, shook them off – either of their own accord or at the urging of a determined coach – and got back in the game.  That’s just the way it was.  But not these days, although I’m sure there are still instances where the rules are bent.

Thankfully, the new normal is to take every concussion seriously.  And there are quick and easy ways to assess the presence of a concussion right there on the field.  Then there are protocols for when the danger has passed and normal activity can be resumed.  It is much more likely that any error will be on the side of caution.  I am particularly glad this is the case since I have a daughter who plays lacrosse, a fast moving game with a very hard ball where no one walks softly, but they all carry big sticks.

One other reason I am concerned about head injuries of all kinds is that every head injury is likely to include disturbances in the visual process.  People with brain injuries often experience focusing instability, double vision, visually related headaches and tracking difficulties.  There can also be problems with balance associated with a brain injury and the visual process is intimately related to balance.  Any of these visual disturbances, alone or in combination (which is more likely), can cause changes in comfort, performance, behavior or personality.  Some visual changes resulting from head injuries are subtle, most are not.  Even symptoms that are subtle can lead to more problematic adaptations and compensations over time, which could mean a more challenging recovery process.

I have been working with people who have sustained brain injuries for as long as I’ve been in practice.  Very early in my career I met a woman who had been picked up by a tornado and deposited several blocks away, hitting her head.  She was not bleeding but was briefly knocked out.  She was fairly quickly discharged from emergency care and went on about her life.  Or so it seemed.  She was unable to focus at work, making many previously uncharacteristic mistakes, and fatiguing easily.  Things continued this way though nobody put two and two together until our meeting, which consisted of her acting as a volunteer while I demonstrated some vision therapy techniques during a lecture/workshop I was giving in Kentucky (I practice in Pennsylvania).  This woman couldn’t figure out why she was suddenly having so much trouble since the doctors all said she was fine.  Her boss was becoming more and more impatient with her poor performance and inability to sustain even this level of activity for a full day.  I was able to help her better understand why she was having some of the problems she was experiencing.  A big part of her problem was the disruption to her visual process.  I was able to steer her in the right direction as far as treatment and I did see her once in my office in order to more thoroughly evaluate her situation and prescribe new lenses, which had an immediate positive impact on her life.

Many behavioral optometrists are experienced with managing the visual challenges associated with traumatic brain injury.  A behavioral optometrist who is familiar with evaluating and treating people with acquired brain injury should be consulted to assess the visual status of anyone dealing with any kind of head injury.  While other health care professionals are important to the recovery process when a head injury occurs, there are no other professionals who understand the nuances of the visual process particularly in the context of a brain injury as a behavioral optometrist does.  The remediation of visual problems with vision therapy and the strategic use of lenses is usually a critical aspect of the overall recovery process for people with acquired brain injury.

Next time: Who You Calling Lazy?

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