Introduction

Chairman Mitchell, Ranking Member Brown-Waite, and Members of the House Veterans Affairs Subcommittee on Oversight and Investigations; on behalf of Neuro Vision Technology (NVT) I would like to thank you for this opportunity to present testimony on Traumatic Brain Injury (TBI) as it relates to vision.

Neuro Vision Technology Pty Ltd has developed the NVT Neurological Vision Rehabilitation System which specializes in the assessment, training and management of people with Neurological Vision Impairments (“NV Impairments”) following traumatic brain injury. NVT provide the equipment and training to professional paramedical and rehabilitation staff who are then responsible for assessing and training the patient with neurological vision deficits.

No comparable equipment and training program exists internationally outside of Australia despite recognized need within the Acute and Rehabilitation Hospital sectors and blindness services.

Prevalence of Neurological Vision Impairments

Previous research indicates:

• Between 30% and 35 % of the population diagnosed with acquired and traumatic brain injury suffer from associated neurological vision impairment1

NV Impairment can be a result of stroke or traumatic event such as a car accident or military injury.

NV Impairment rehabilitation in the past has “fallen through the gaps”. The primary vision impairment agencies such as the not for profit Blindness agencies and Blind Rehabilitation Centers (BRC) have either been unaware or have not invested significant resources in NV Impairment rehabilitation. Major stroke and rehabilitation hospitals have also neglected the need for a standardized functional visual assessment as part of a minimum standard of clinical care in the rehabilitation of brain injury.

Historically, rehabilitation programs have focused on the physical recovery (Physiotherapy programs), implementation of strategies designed to maximized independence in activities of daily living (Occupational Therapy programs) and Speech Therapy. The incidence of language deficits following TBI is equivalent to that of NV impairment following TBI, however, assessment and specific therapy to reduce the impact of NV impairment is currently not standard practice in the majority of rehabilitation programs. Assessment and training should immediately become part of the clinical standard of care for the rehabilitation of Neurological Vision Deficits.

Some statistics which have been released by the Department of Veteran Affairs Polytrauma Unit and Western Blind Re habilitation Center, Palo Alto, indicated that:

• “67% of poly trauma patients seen to January 2006 have a severe vision impairment”
• “90% injured as a result of combat, have a severe neurological vision impairment”

Definition of Neurological Vision Impairment

The most common field deficit following TBI is Homonymous Hemianopsia (HH); half of the vision is lost in both eyes. HH impacts on all areas of activities of daily living, writing, reading, shaving, eating, dressing and mobility in busy or unfamiliar areas.

Additionally patients can be unaware of the extent of vision loss which is call Visual Neglect. The patient may only eat half the food on his plate, shave half of his face, be disorientated in space because he only sees one side of the world, e.g. moving from his room to physiotherapy he sees one side of the corridor and on the way back only sees the other side and therefore thinks he is in a totally different place.

Patients can also suffer from Visuo-spatial deficits whereby they can not recognize their environment no matter how familiar it was previously, they may not recognize familiar faces of their mothers, wives or family members. These patients quite often do not have a visual field loss or ocular motor problem and therefore it is extremely hard to diagnose.

NVT have developed a standardized Vision Rehabilitation System that offers an assessment, training, outcome measures, management and research solution for the rehabilitation of NV Impairment.

Rehabilitation of Neurological Vision Impairments

While clinical vision assessments may be provided by Optometrists and Ophthalmologist, these usually occur much later than other rehabilitation assessments, some times the delay can be as long as many months. Many of the more complex visual perceptual deficits go undiagnosed and untreated for even years.

World leading neuro-psychologists and professionals in neurological rehabilitation centers are outlining the real issue with neurological vision impairment. In research studies in the US it has been disturbing to find published articles which outline the following:

• “50% of the patients in a head trauma rehabilitation centre show visual systems disorders not assessed before, although most of the patients were chronic and had been treated in other hospitals previously”2

This in part is due to vision assessment not being part of a clinical standard and partly due to the staff not being trained in appropriate assessment and rehabilitation techniques for neurological vision deficits.

Patients referred to Blind Rehabilitation Centers and / or Low Vision Clinics are often provided with programs designed for ocular disorders e.g. glaucoma, macular degeneration. Most staff have minimal understanding of the additional cognitive and physical deficits associated with traumatic brain injury and may provide ineffectual or inappropriate interventions.

It can be argued that Neurological Vision Rehabilitation Therapy should be provided by a specialized profession equivalent to traditional therapy providers such as Speech Therapists given that the incidence of vision deficits following TBI is equivalent to that of language deficits following TBI.

NVT Neurological Vision Rehabilitation System

NVT Vision Rehabilitation System is not just a device but a therapy intervention program that actively transfers skills learnt in early phase recovery into functional tasks graded for a variety of settings, thus catering for the different entry and exit levels of a patient’s performance.

It is based on assessment and training therapy programs which have been successfully provided in acute and rehabilitation hospitals in Australia for over 20 years to clients suffering from a Neurological Vision Impairment due to Acquired and Traumatic Brain Injury.

The NVT Neurological Vision Rehabilitation System’s main objective is to assess and train the patient in compensatory scanning techniques which can be transferred in all activities of daily living such as mobility, orientation, reading, personal safety and quality of life. It is designed for early intervention following trauma and to be conducted in an interdisciplinary setting to support other rehabilitation therapies.

The Assessment is holistic in its format and has many components including neurological behavior checklists, activities of daily living, functional vision screening, quality of life measure and mobility assessment. The Assessment also includes the NVT Scanning Device which displays various sequences of lights to diagnose the presence of visual field loss, scanning deficits and other visual perceptual deficits including visuo-spatial neglect. The light box has a series of colored lights spanning 1.8 meters in length to simulate the degree of scanning required for mobility tasks, such as crossing roads.

The Training is designed to provide scanning exercises that encourage use of residual vision in compensatory scanning techniques. The device is portable to allow training to be carried out in the acute hospital, rehabilitation hospital or the patient’s home. Therapy intervention can be evaluated by using the standardized assessment component post training to demonstrate patient improvement by evidence based outcomes.

Attention to required Research protocols within the software, which are based on standardization of assessments and therapy, allow for comparisons between base level and post intervention over a number of outcome measures.

Validation in the form of clinical trial/trials with ethics approval, for comparisons between patients with immediate and delayed NVT Vision Therapy intervention has commenced and will be completed in 2009/10. The study is being conducted by an independent organization (the Royal Society for the Blind South Australia “RSB”) using patients drawn primarily from Stroke Rehabilitation Unit of the Repatriation General Hospital, Adelaide South Australia and in conjunction with Flinders University.

International interest in collaborative research has been marked and currently two grant applications have been lodged in the US. It is likely in the next six months another grant application in Scotland will be lodged.

Training of Rehabilitation Staff

An integral part of the NVT Neurological Vision Rehabilitation System is the training of staff in the use of the assessment and training protocols and tools. NV Impairment has been a neglected area of primary health care and coverage for many years. Brain Injury Rehabilitation programs have traditionally focused on physical, cognitive and language therapies and often ignore the impact of visual deficits. This is due in part to the lack of quality assessment and therapy intervention tools.

The complexity of injuries, in addition to vision loss, made these cases challenging for vision rehabilitation programs, especially when the injury involved a traumatic brain injury. Staff are challenged because historically Blind Rehabilitation programs are designed to address the needs of an aging veteran population with age-related eye disease and ocular problems. Staff need to understand and be trained in recognizing the difference between ocular intervention and neurological vision impairment intervention e.g. brain not eyeball.

The advents of the Iraq and Afghanistan conflicts have highlighted Traumatic Brain Injury and subsequently the relationship of Neurological Vision Deficits. Rehabilitation professionals are realizing they are not equipped to provide support and training and see the NVT Vision Rehabilitation system as a concrete means of providing a standardized assessment and training program with built in outcome measures.

The NVT professional training program is delivered in a structured manner and provides VIST’s, BROS and Occupational Therapists with:

• Theoretical aspects of Traumatic Brain Injury and the Cortical Vision System
• Training in the use of the NVT Scanning Device as an assessment tool for determining the presence of Homonymous Hemianopia and/or visuo-spatial neglect
• Training in the use of the NVT Scanning Device as a therapy tool for enhancing visual function
• Skills that will enable the Vision Therapist to transfer these scanning strategies to the veteran’s home and community setting
• Comprehensive manuals, workbooks lecture notes to support the training program.
• Currently requires four weeks intensive face to face contact with service provider.
• Competency measured after three months practical experience.

The Palo Alto Blind Rehabilitation and Polytrauma staff, and the Tampa Polytrauma rehabilitation staff, who have trained with the NVT system rightly see themselves as world leaders in the area of Neurological Vision Rehabilitation and have already seen many success in the short time they have been working with veterans. They are finding many advantages in providing the Neurological Vision Rehabilitation programs as part of the comprehensive interdisciplinary rehabilitation service within the Polytrauma Rehabilitation Centers. 

Overview of Case Studies

I have outlined briefly four veterans with Traumatic Brain Injury who have made good improvements in their visual functioning and rehabilitation following NVT assessment and training at Palo Alto since NVT training commenced in October 2006.

• 22yr old Veteran injured in Iraq by IED, Level 4 Coma Stim, suffering from right homonymous hemianopia, visual neglect, language deficits, and related cognitive issues, injured lower limbs, right hemiparesis.

Training intervention: Over a period of four weeks the BROS was able to attain systematic scanning in intact field of view and in deficit field where there was a strong presence of visual neglect. Veteran’s deficit right field of view was stimulated so that spontaneous scanning was initiated by the veteran. Other nursing and rehabilitation staff were provided with strategies for use in day to day therapy programs where vision rehabilitation could be integrated.

• 24yr old Veteran injured in Iraq by IED, loss of limb, loss of speech, Frontal-parietal-occipital lobe damage, wheelchair mobility, bi-lateral visual field loss.

Training intervention: On assessment this client was unable to travel safely or independently and was maneuvering his wheelchair from one side of the corridor to the other. He was disorientated in space and unaware of the need to scanning bi-laterally to compensate for his field loss. Outcomes on training intervention included safe independent wheelchair mobility to therapy sessions, dining room and some outdoor travel.

• 22 yr old female veteran who was involved in a motor vehicle roll over in Germany, July 2006. Frontal lobe, bi-temporal, bi-parietal lesions and occipital craniotomy, visuo-spatial/perceptual deficits, quadrantanopia, hip and leg injuries, related cognitive deficits including visual inattention.

Training intervention: The veteran had difficulties with spatial orientation and finding her way to therapy sessions. She was easily distracted and had balance and gait problems. On completing her vision rehabilitation training with the BROS at Palo Alto she was able to live independently, return to study, plan her weekly schedules and visit the local supermarket to do her weekly shopping.

• Veteran injured in Korea in 1951, gunshot wound to the head, received no vision therapy until February 2007, has a remaining vision intact field of superior right quadrantanopia.

Exert from his testimonial: On June 13,1952 1 was shot through the head during Korean War combat. The bullet went through the skull behind the ears, blew off the back of the skull, damaged the occipital lobe, and left me legally blind. I lost 75% of the visual field in both eyes. After a lengthy stay in an Army hospital., 1 was discharged without the benefit of any rehabilitative therapy for my loss of vision.

Fifty-five years later I discovered the Veteran's Administration Western Blind Rehabilitation Center (WBRC) in Palo Alto, California.

I was admitted to the Center on January 10, 2007: The staff and I soon realized that their standard program was geared to helping people suffering from vision loss due to eye pathology, not loss of vision due to traumatic brain injury.

Therapy for loss of vision due to eye pathology relies heavily upon magnification devices. A person with vision loss due to traumatic brain injury does not need magnification aides, but does need to be trained to bring those objects, which he may not see, into the undamaged portion of his visual field.

Upon realization that the normal curriculum at the Center was not appropriate for traumatic brain injury vision loss, Elizabeth Jesson, WBRC Director, removed me from their standard program and assigned Visual Therapist, Scott Johnson as my coordinator.

Mr. Johnson employed a system developed in Australia by Gayle Clark entitled Neuro-Vision Technology. This system trains a person to move the undamaged portions of his visual field to cover areas where vision is unpaired.

Even though I was fifty-five years late in receiving any visual therapy, I feel this system was beneficial. The Neuro-Vision Technology system would be even more successful if applied as soon as the WBRC becomes responsible for a veterans rehabilitation.

Mr. Johnson has been assigned to develop a program for the WBRC utilizing the Neuro-Vision Technology System. This program will give the WBRC the capability of providing vision loss rehabilitation to the large number of veterans who have received traumatic brain injuries from roadside bombs and other explosive devices in the OIF. and OEF.

Please lend your support and encouragement to this proposed program when it comes to your attention. Sincerely, Rodger L. Thisdell

Conclusions

The NVT Neurological Vision Rehabilitation System and was recently featured favorably in the San Francisco Chronicle3. Staff have been trained in Australia and the UK including staff funded by the Scottish War Blinded. The current technology is targeted at improving mobility and functional field of vision via specialists in the rehabilitation, optometry and neuro-ophthalmology services.

The Department of Defense (DoD) and VA Health systems are seen as the gold standard in health services. The implementation of the NVT Vision Rehabilitation System within the VA Health system promotes the knowledge that it is a leader internationally and providing the best possible care for those veterans with TBI and related neurological vision impairments. It recognizes that Neurological Vision Impairment requires early assessment and rehabilitation intervention and that vision therapy is an integral part of the holistic rehabilitation required for the OIF and OEF service members.

The NVT Neurological Vision Rehabilitation System’s main objective is to assess and train the patient in compensatory scanning techniques which are then transferred into all activities of daily living such as mobility, orientation, reading, personal safety and quality of life. It is designed for early intervention following trauma and to be conducted in an interdisciplinary setting to support other rehabilitation therapies.

It must be remembered that there is no “short cut fix” when talking about rehabilitation for Traumatic Brain Injury, in most cases this is a life long process, but experience has shown that early intervention and specific intervention for vision deficits improves quality of life, decreases the level of medical intervention and decreases the level of support required in the community setting once veterans are discharged from rehabilitation programs.

Chairman Mitchell and Ranking Member Brown-Waite and members of the Subcommittee, I would ask that you consider the following:

1. While clinical vision assessments may be provided by Optometrists and Ophthalmologist, these usually occur much later than other rehabilitation assessments, some times the delay can be as long as many months. Many of the more complex visual perceptual deficits can go undiagnosed and untreated for even years.

Recommendation: The assessment and training of veterans with Neurological Vision Deficits should be implemented in the early stages of recovery and become part of the clinical standard of care for the rehabilitation of Traumatic Brain Injury.

2. Patients referred to Blind Rehabilitation Centers and / or Low Vision Clinics are often provided with programs designed for ocular disorders e.g. glaucoma, macular degeneration. Most staff have minimal understanding of the additional cognitive and physical deficits associated with traumatic brain injury.

Recommendation: BROS, VIST’s and Occupational Therapists be trained to provide Neurological Vision Therapy assessment and intervention programs in the interdisciplinary settings of Polytrauma, Polytrauma Network Sites and Blind Rehabilitation Centers.

Chairman Mitchell, I have spent 25 years of my life working as a clinician in the area of vision rehabilitation for patients with neurological vision impairments. I have seen many successes over the years and have many stories to tell. My key motivator is improving patient quality of life and as such I believe passionately that a comprehensive commitment to vision equipment such as Dynavision, Nova Vision and Neuro Vision Technology will provide internationally recognized, gold standard rehabilitation services to US veterans whom deserve only the best.

Neuro Vision Technology strongly supports the recommendations of the Blinded Veterans Association and thanks you sincerely for the opportunity of testifying to the Subcommittee today.

Gayle Clarke: Chief Executive Officer

Gayle studied at the Pennsylvania College of Optometry, Graduate Studies for a Masters of Science in Vision Rehabilitation (pending). She also has a Graduate Diploma in Management, and a Diploma in Orientation & Mobility. Gayle has over 25 years experience in the area of vision rehabilitation, specializing in Low Vision and Neurological Vision Impairment. She has undertaken university lecturing at Graduate and Masters level, developed staff training courses, co-coordinated international conferences, and is a committee member of the International Mobility Committee.

Gayle founded Neuro Vision Technology Pty Ltd in July 2005 with four colleagues to ensure that Neurological Vision Rehabilitation was available not only in Australia but internationally for patients with Acquired and Traumatic Brain Injury.

[1]Zihl, Josef. “Oculomotor scanning performance in subjects with homonymous visual field disorders”, Visual Impairment Research 1999. Vol. 1, No. 1, pp 23-31.

[2] Gianutsos, R. “Vision rehabilitation following acquired brain injury. In: Gentile, M. ed Functional visual behavior. A therapists guide to evaluation and treatment options. Bethesda, MD: American Occupational Therapist Organization, 1997:267-294.

[3] “Fernandez, E (2008) “New Treatments for Traumatic Eye Injuries,” San Francisco Chronicle, March 9, 1.