Phil Jones - Low Vision

COMMON APPLICATIONS OF THE DYNAVISION D2™

FOR TREATMENT OF LOW VISION

Phil Jones Founder and President

Jennifer Fortuna, MS, OTR/LBusiness Training Coordinator

OVERVIEW

Introduction Occupational Performance Applications Objectives Treatment Strategies Programmable Options Report Management Normative Data Modifications Tachistoscope Questions

INTRODUCTION

Originally developed for sports vision training of athletes, the Dynavision D2™ has proven effective for use in visual, cognitive and physical rehabilitation after brain injury and stroke (Akinwuntan et al., 2008; Anderson et al., 2011; Klavora et al., 1995; Klavora et al., 2000; Klavora & Warren, 1998; Vesia et al., 2008; Hunt, 2008).

INTRODUCTION

Operating System:

Adjustable light board (4’ x 4’ )Wall or stand mount installationNetbook interfaceAuditory feedback Game-like presentationPrinter (optional)

OCCUPATIONAL PERFORMANCE

OCCUPATIONAL PERFORMANCERole of the Central Nervous System:

Take in/process sensory stimuli from the environment Filter out irrelevant information Prioritize Adapt to change Regulate arousal levels Produce a behavioral response

According to Warren (1993) 90% of the information take in from the environment comes from visual stimuli.

Occupational performance is dependent on the ability of the CNS to process incoming visual stimuli from the environment.

OCCUPATIONAL PERFORMANCEVisual Input:

Cognitive processing (visual cognition) Problem solving Decision making Motor control Ability to navigate static/dynamic environments Postural control Social interpretation Visual cognition builds the foundation for academics, leisure

activities and many vocations

OCCUPATIONAL PERFORMANCEVisual Impairment: Disease Trauma Age

Dysfunction: Influences cognitive processing Impairs problem solving and decision making Increases frustration and anxiety Reduces self-confidence and self-awareness Prevents the CNS from producing an adaptive response Negatively impacts participation in meaningful occupations

Warren’s Visual Perceptual Hierarchy (Warren, 1993)

A visual perceptual hierarchy used to evaluate and treat underlying visual deficits.

Higher level skills evolve from integration of lower level skills. All skills interact and are affected by disruption.

Warren’s Visual Perceptual Hierarchy (Warren, 1993)

Identification and remediation of deficits in foundational skills allows for normal integration of higher level skills.

Visual processing builds the foundation for cognitive processing. Altering vision will alter cognition.

Highest level of visual integration is visual cognition.

“The ability to mentally manipulate visual information and integrate it with other sensory information to solve problems, formulate plans and make decisions” (Warren, 1993).

The Dynavision D2™ has been recognized as the premier visual-motor reaction training system for over 25 years.

Programmable options standard with D2™ software enable the clinician to facilitate individualized treatment programs for clients of different ages, abilities, and conditions.

APPLICATIONS

The D2™ is utilized by a diverse group of medical professionals.

Physical Therapy Occupational Therapy Speech Therapy Physiotherapy Optometry Neurology

APPLICATIONS

Visual Rehabilitation

Visual reaction time Visual-motor integration Visual-perceptual processing Visual-spatial integration Visual processing speed Visual attention Visual memory Binocular vision Contrast sensitivity Central/peripheral visual integration Compensatory visual field training

APPLICATIONS

Cognitive Rehabilitation

Attention regulation Problem solving Impulse control Insight into disability Vestibular function Executive function Sustained and divided attention Metacognitive strategy training Sequential and working memory Increase patient insight into underlying deficits

APPLICATIONS

Physical Rehabilitation

Bilateral coordination Eye-hand coordination Manual dexterity Standing activity tolerance Physical strength and endurance Static and dynamic balance Postural control Seated and standing balance Functional mobility Upper extremity range of motion Reach outside base of support

OBJECTIVES

Use visual dysfunction to explain functional limitations. Improve functional performance in meaningful occupations. Increase client insight into impact of visual impairment.

OBJECTIVES

Dysfunction:

Identify and remediate deficits in lower level visual skills to integrate higher level visual skills.

Identify visual strengths to facilitate use of remaining vision.

Link functional impairment to visual impairment.

Help patient find new ways of completing meaningful activities instead of giving them up.

OBJECTIVES

Functional Performance:

Initiate wide head turns towards the affected visual field.

Increase speed and accuracy of eye movements.

Improve visual attention to detail and contrast.

Shift attention between central and peripheral visual field.

Incorporate body movements to improve vision and perception.

OBJECTIVES

Insight:

Provide auditory cues (finger snapping) to remind client to look at the affected visual field.

Share clinical observations with the client. “When you did this, I noticed this happened.”

Identify the client’s own compensatory strategies and provide opportunities use these strategies whenever possible.

Verbal prompts: “Pay extra attention to the affected side,” “Where will I ask you to look?” “What part of this task did you find difficult?”

TREATMENT STRATEGIES

Determine current level of function Identify functional impairment Set the client up for success Avoid frustration

Utilize a vision screening tool such as the Colenbrander Low Vision Measurement System. Letter chart for visual acuity down to 20/1000 Reading cards with standardized paragraphs Mixed contrast cards for contrast sensitivity screening

Identify client’s own perceptions of visual challenges Reading Color recognition

Activate the quadrant(s) on the D2™ that correspond with the client’s strongest visual fields.

Initiate saccadic training to help client compensate for field loss.

Dim lights to help client locate the glow of red lights and direct compensatory head movements.

For patients with glaucoma, encourage use of functional vision to compensate for loss of peripheral vision.

Encourage wide head turns in the beginning. Gradually reduce head movements to encourage a wider saccade.

Example:

Mode: Proactive (Mode A)T-Scope: OffQuadrants: Upper/lower left Rings: AllRun Time: 60 seconds

Suggested Instructions:

“Turn your head towards the left side of the light board. When you see a red light flash, hit it as fast as you can. Keep hitting the red lights until the run is over.” f

Clinical Observations

Ability to initiate wide head turns toward affected side Ability to shift attention between visual fields Unsteady balance (seated and/or standing) Level of insight into impairments

Objective Data

Score Average reaction time Significant differences in score/reaction time between quadrants Standing/seated activity tolerance

PROGRAMMABLE OPTIONS

PROGRAMMABLE OPTIONS Light board with 64 LED buttons Five concentric rings Four quadrants Modes (A,B,C, Reaction Test) Green Lights (percentage/area) Tachistoscope (T-Scope) Run time Light speed

PROGRAMMABLE OPTIONSRings Activate or deactivate the light board by individual rings

PROGRAMMABLE OPTIONSQuadrants

Activate or deactivate the light board by quadrant

Run Time T-Scope Make Repeatable Quadrants Rings

Proactive (Mode A)A light will illuminate and the patient must touch the button to deactivate it. When one light is deactivated, another will appear at a random location. This cycle continues until the run is over.

Run Time Lights (speed, color, area) T-Scope Make Repeatable Quadrants Rings

Reactive (Mode B)A light will illuminate for a preset length of time. The patient must deactivate the light before it moves to a new random location. This cycle continues until the run is over.

Run time Light speed

Scan (Mode C)A light will travel around the periphery of the 6th ring at a preset speed, changing directions every 15 seconds. The patient will track the light without moving his/her head until the run is over.

PROGRAMMABLE OPTIONSReaction Time Test (Mode D):The patient will hold down an illuminated button, until another button appears at a random location, then release the first button to strike the second button as quickly as possible. This mode consists of six tests, three for each hand.

Establish visual motor baseline Monitor progress over time

PROGRAMMABLE OPTIONSGreen Lights• Select the percentage and area of green lights

Tachistocope (T-Scope) Basic and Advanced Options Divide visual attention between the light board (peripheral

vision) and the LED screen (central vision).

Run Time Select length of run time

Light Speed Select speed of flashing lights

REPORT MANAGEMENT

Performance data is quantitative and objective to ensure accurate reporting for initial baseline evaluation and progress monitoring.

REPORT MANAGEMENT

Formats:1. Score2. Reaction Time 3. Results by Quadrant4. Text report 5. Time/score breakdown

Easy to read Printable Objective Stored in patient history

REPORT MANAGEMENT

Results by Quadrant:

Total score and average reaction time Divided by quadrant and color Separates red/green light scores and average reaction times

REPORT MANAGEMENT

Text Report:

Total Score and average reaction time Displays fastest/slowest reaction time Statistics on quadrants, rings, hits, and average reaction time

REPORT MANAGEMENT

Time/Score Breakdown:

Total score and average reaction time Provides hits/lights by interval Displays location of hits on light board

REPORT MANAGEMENT

Red Light Score:

Red Light Score Red Score Lights Red Average Reaction Time

NORMATIVE DATA

Normative Data

NORMATIVE DATA

Normative Data

MODIFICATIONS

MODIFICATIONSAdjust for the client’s strengths/needs:

Remove visual/auditory distractions Dim lights to increase contrast Adjust positioning/posture Consider “add-on’s”

MODIFICATIONSPositioning:

Seated vs. standing Sturdy chair (stand and reach) Bar stool

Static vs. dynamic Exercise ball Bosu ball T-Stool Balance board Foam cushion Incline/wedge

MODIFICATIONS

Red/Green Glasses (Bernell.com) Assess binocular vision 50% green lights

Rear View Mirror Divided attention Driver rehabilitation

Head Lamp Improve eye-hand coordination Dissociate eye-head movement

MODIFICATIONS

Red and Green Gloves Provide visual cues Match to red/green buttons Assist with crossing midline Left/right directionality

Picture Cards Visual field integration Sequential memory Divided attention Multi-tasking

TACHISTOSCOPE

TACHISTOSCOPE (T-SCOPE)

Select from basic or advanced options

T-SCOPE

The T-Scope enables the clinician to grade visual and cognitive demands quickly and easily.

Example: Three memory tests of graded complexity

T-SCOPE

Memory Test 1:

Step 1: Click Add ProgramStep 2: Select Reactive Mode Step 3: Activate rings 1, 2, and 3

T-SCOPE

Memory Test 1:

Step 4: Under T-Scope Option, click Change. Step 5: Set flash at 1 digits for 1.00 seconds. Click OK.

T-SCOPE

Memory Test 1:

Step 6: Click Save Program. Step 7: Name the program Memory Test 1. Click OK. Step 8: Click Run Program.

T-SCOPE

Memory Test 1:

Verbal Instructions: “Single digit numbers will flash on the screen. Hit the red buttons as quickly as you can. At the same time, call the numbers out.”

Data Management: Note the client’s score, ability to call numbers accurately.

Clinical Observations: Left/right symmetry of the upper extremities Unsteady balance Alternating hands instead of using hand that is closest Pauses before striking or calling/adding numbers

T-SCOPE

Memory Test 2:

T-SCOPE

Memory Test 2:

T-SCOPE

Memory Test 2:

Step 6: Click Save Program. Step 7: Name the program Memory Test 2. Click OK. Step 8: Click Run Program.

T-SCOPE

Memory Test 2:

Verbal Instructions: “Single digit numbers will flash on the screen. Hit the red buttons as quickly as you can. Call out the first number, remember the second number, and then call out the sum. For example, if the first number is 4 and the second number is 3, you would say 4 followed by 7.”

Data Management: Note client score, ability to call and add numbers accurately.

T-SCOPE

Memory Test 3:

T-SCOPE

Memory Test 3:

T-SCOPE

Memory Test 3:

Step 5: Under Lights/No Green Lights, click Change. Select 20%.

T-SCOPE

Memory Test 3:

Step 6: Click Save Program. Name the program Memory Test 3. Click OK. Step 7: Click Run Program.

T-SCOPE

Memory Test 3:

Verbal Instructions: “Single digit numbers will flash on the screen. Hit the red buttons as quickly as you can. Call out the first number, remember the second number, then call out the sum. When you see a green light, call green. Do not hit green.”

Data Management: Note client score, ability to call and add numbers, ability to call green.

KEY POINTS The D2™ is utilized by a diverse group of medical professions.

Programmable options facilitate “just-right” challenges appropriate for clients of various ages, stages, and conditions. The applications are endless!

The Dynavision D2™ increases insight into underlying deficits and supports generalization of new skills into everyday life.

D2™ software produces objective performance data to establish accurate baseline measurements and monitor progress.

Modifications facilitate creativity. Think outside of the box!

QUESTIONS?

REFERENCESAkinwuntan, A.E., Devos, H., Verheyden, G., Baten, G., Kiekens, C., Feys, H., & De Weerdt, W. (2010). Retraining moderately impaired stroke survivors in driving-related visual attention skills. Topics in Stroke Rehabilitation, 17(5), 328-336.

Anderson, L., Cross, A., Wynthein, D., Schmidt, L., & Grutz, K. (2011). Effects of Dynavision training as a preparatory intervention post cerebrovascular accident: a case report. (2011). Occupational Therapy in Health Care, 25(4), 270-282.

Cole, M.B., & Tufano, R. (2008). Applied theories in occupational therapy. Thorofare, NJ: SLACK Incorporated.

Colenbrander Low Vision Measurement System. (n.d.). Retrieved from http://www.ski.org/Colenbrander/Images/LV_system.pdf

REFERENCESHunt, L.A., & Arbesman, M. (2008). Evidence-based and occupational perspective of effective interventions for older clients that remediate or support improved driving performance. American Journal of Occupational Therapy, 62, 136-148.

Klavora, P., Gaskovski, P., & Forsyth, R.D. (2000). Test-retest reliability of three Dynavision tasks, Perceptual and Motor Skills, 80, 607-610.

Klavora, P., Heslegrave, R.J., & Young, M. (2000). Driving skills in elderly persons with stroke: comparison of two new assessment options. Archives of Physical Medicine and Rehabilitation, 81, 701-705.

Klavora, P., Gaskovski, P., Heslegrave, R.J., Quinn, R.P. & Young, M. (1995). Rehabilitation of visual skills using the Dynavision: a single case experimental design. Canadian Journal of Occupational Therapy, 62, 37-43.

Toglia, J. & Abreau, B. (1987). Cognitive rehabilitation. New York, NY: Authors.

REFERENCESWarren, M. (1990). Identification of visual scanning deficits in adults after CVA. American Journal of Occupational Therapy, 44, 391-399.

Warren, M. (1993). A hierarchical model for evaluation and treatment of visual perceptual dysfunction in adult acquired brain injury. I. American Journal of Occupational Therapy, 47, 42-54.

Warren, M. (1993). A hierarchical model for evaluation and treatment of visual perceptual dysfunction in adult acquired brain injury. II. American Journal of Occupational Therapy, 47, 55-66.

Zoltan, B. (2007). Vision, perception, and cognition: A manual for the evaluation and treatment of the adult with acquired brain injury (4th ed.). Thorofare, NJ: SLACK Incorporated.

Phil Jones - Low Vision

dynavision international

visual processing

visual information

dynavision d2

incoming visual stimuli

occupational performance

underlying visual deficits

klavora warren

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