Why a “Cocoon Management Model” for neuro-developmental vision problems can be detrimental

Evidence-based research in medicine has confirmed that those who have suffered from chronic symptoms following a concussion, otherwise known as an mTBI (mild traumatic brain injury), experience, among other health concerns, vision problems involving sensorimotor (eye coordination) such as

• Oculomotor Dysfunction
• Convergence Insufficiency
• Convergence Excess
• Accommodative Dysfunction
• General Binocular Dysfunction

In addition dysfunctions in visual perception, visual processing and integration are common. These conditions will trigger symptoms involving, double vision, poor depth perception, transient blurred vision, light sensitivity, headaches associated with reading, trouble keeping their place when reading, poor attention and concentration, reduced confidence and much more. These vision problems can have a tremendous impact on a patient’s “wellness” that negatively affects the post-concussed individual’s ability to go back to the classroom or to work. 

Published in the Journal of the American Medical Association (JAMA) Neurology, April 2018, Dr. Christopher C. Giza, et al, wrote an article entitled: Determining If Rest Is Best After Concussion. What the authors outlined is that in the past, the accepted practice in medicine for those who have been concussed was “cocoon therapy”;  a form of severe restriction of activity designed to reduce brain activity by reducing sensory, motor and cognitive stimulation. However, new research in neuroscience indicates that the “rest is best approach” model of treatment can actually be detrimental to the patient’s long term recovery. Instead what they concluded was, “a more refined approach of individualized management of activity after mTBI, with initial brief rest followed by controlled reintroduction of cognitive activities, non risky physical activities and eventually a return to normalcy”, is good for rewiring brain function. This is also spelled out in the research published in January 2016 in ScienceDirect entitled: The interplay between neuropathology and activity based rehabilitation after traumatic brain injury,  where there are multiple studies that show, following the initial “acute phase” of the  injury, it is critical to the patient’s recovery to have therapeutic physical activity and rehabilitation that promote adaptive neuroplasticity and hence recovery.

Therefore research is now showing that “rest is not best” when it comes to neuro-development for those who are dealing with the consequences of an mTBI. Instead, a proactive therapeutic action-oriented treatment plan is more effective. When this involves dysfunction in sensorimotor visual coordination and/or visual perceptual, processing and integration, office-based neuro-optometric vision rehabilitation should be an integral part of the patient’s overall care.

But, if this is true for those who have had an mTBI,  what about when a patient presents with a history of no trauma, yet has dysfunction in sensorimotor and/or visual perceptual abilities? The cause of these dysfunctions can be associated with delays in neuro-development and often associated with many of the same signs and symptoms found with mTBI. They also commonly affect reading and learning which impacts attention and concentration and often interferes with classroom performance.

These conditions involving sensorimotor, binocular vision (eye teaming), oculomotor (eye tracking) and accommodation (eye focusing) and visual perception, processing and integration have been outlined in multiple research studies. But when it comes to prescribing treatment, too often patient (or parents of children) are told that they will “outgrow” the problems or that they should use compensatory strategies for reading and learning thereby allowing the patient to accept the problem and apply techniques to “work around” the deficit.

The question for physicians, optometrists, ophthalmologists, psychologists and all those in the medical community who evaluate children and adults that present with chronic signs, symptoms and behaviors that are similar to those of an mTBI, yet there is no history of trauma:  What is best for the patient? “Rest”, ie “let time take its course” and hopefully all will work out? Or, to be more proactive by identifying, diagnosing and helping the patient to obtain targeted vision rehabilitation/vision therapy to accelerate the neuro-development of the visual system responsible for the dysfunction?

In conclusion, while conservative models of care come with good intentions, not having awareness of the clinical science may contribute to unanticipated consequences in the lives of patients. When a neuro-developmental vision problems exists, just as in the patient who has chronic symptoms following an mTBI, rest is not best. What’s best for the patient is the opportunity to take action and develop function. Anything less is a Cocoon Management Model of care.

Dan L. Fortenbacher, O.D., FCOVD