We have a considerable amount of information on our visionhelp website as well as on my practice website about acquired brain injury, and of course NORA is a treasure trove of information on the subject. As professionals we tend to see a skewed population of individuals who have ruled out other potential causes for their signs or symptoms before coming to us. When the problem is blurred vision, double vision, light sensitivity and so forth, it is more likely that patients will come to us sooner rather than later in the process, and treatment typically consists of the specialized application of lenses, prisms, filters, and active vision therapy. Such was the case with John, a patient who came to us having experienced a head injury which rendered returning to work impossible. He felt groggy and lightheaded when trying to do any kind of visually demanding task, whether it was working on his computer or driving. He had no demonstrable visual field loss, double vision, or midline shift, but the more subtle sequelae of ABI resulting in poor visual stamina and visual instability.
John, in his early 50s and self-employed, had been making steady progress through optometric vision therapy. He was very diligent with keeping his office visits and in following through on his home therapy. As pleased as he was with his progress, and his beginning to get back to work, there were times when felt he just couldn’t think clearly. We’ve made great strides in educating the public about optometric vision therapy services in my professional lifetime. Yet VT is still a relatively well-kept secret, and John understood in working with us that what we do isn’t fully grasped by the medical establishment. When we conducted a VEP and explained the significance of its results to him, he was excited about sharing it with his neurologist. The neurologist was polite, but didn’t seem particularly interested in the results or in John undertaking vision therapy. His position was that John’s visual function will recover to whatever extent it would recover simply by allowing the passage of more time. How much function, and how much time, was indeterminable.
Used to taking the bull by the horns, John did some further searching online and found a facility in Guelph, Canada that claimed to have a unique form of treatment for post-concussion syndrome pioneered by a physiotherapist, Terry Moore. (The only prior time I had heard of Guelph was through the listmaster of a Phillies online discussion forum that I frequented, Hank Davis, a psychologist at the University of Guelph.) You can read more about Moore’s approach to post-concussion syndrome treatment on his website, and this is the essence as I understand it. When the brain is concussed there is a cascade set off which results in sustained vasoconstriction.
The muscles in the neck and upper back that support the cranium contract from the injury, and receive inadequate blood flow and oxygen. It is as if the brain and its supporting structures are preparing for another blow as a protective mechanism, even though there isn’t any imminent threat. The pulsed stimulation delivered by the MyoWorx device induced biochemical changes in Leukotriene B4 concentration that reduces edema and increases blood flow. This in turn enables the patient to do stretching exercises and receive therapeutic massage that would otherwise be painful or ineffective.
After the intensive two week daily program in the MMTR facility, John called to tell us that the fog had lifted. He was able to think more clearly, and many of the patients who had come to Guelph from all over the world seemed to have similar stories. He was able to undertake the vision therapy procedures we prescribed to be done at home more readily, though he still experienced fatigue and some residual sensory sensitivities. John correctly felt that I’d be intrigued to learn about this approach, and I am. The idea of repetitive trigger point release sounds a bit like the muscle analog of targeted TMS to the cortex.
Terry Moore tweeted about his meeting with Robert Cantu, M.D., who is one of the world’s leading experts on post-concussion issues. If Cantu is interested, I’m interested. I don’t view any of these therapeutic interventions as one being more effective than others. I look at them as potentially synergistic for individual patients. It is logical that some patients receiving Moore’s form of physiotherapy who have lingering visual issues should have the benefit of vision therapy. And now on my radar will be those patients like John for whom a very targeted form of physiotherapy may be needed to maximize outcomes of vision therapy in post-concussive syndrome.