Oculomotor Treatment in Traumatic Brain Injury Rehabilitation: A Randomized Controlled Pilot Trial.

IMPORTANCE: Vision impairments are common after traumatic brain injury (TBI). Little evidence exists to assist clinicians with effective interventions for impaired oculomotor skills in people with TBI. OBJECTIVE: To pilot a randomized controlled trial (RCT) of oculomotor treatment in TBI rehabilitation. DESIGN: An impairment-based oculomotor protocol was compared with an activity-based standard of care in a two-group RCT. Participants were masked to assignment. SETTING: Inpatient rehabilitation. PARTICIPANTS: For 1 yr, 138 people with TBI, ages 18-65 yr, were screened. Twenty-six were eligible; 6 declined. Inclusion criteria: oculomotor impairment. Exclusion criteria: inpatient stay <6 wk, blind, no functional arm use, unable to follow a three-step command, attention <30 min, or in another clinical trial. INTERVENTION: Participants were randomized into an experimental group (n = 10) receiving the Six Eye Exercises protocol or a control group (n = 10) receiving a standard-of-care protocol for 30 min/day, 5 days/wk, for 4 wk. Oculomotor and related functional impairments were measured at baseline and posttreatment. OUTCOMES AND MEASURES: Measures were chosen before the start. Primary outcome measure: Craig Hospital Eye Evaluation Rating Scale for oculomotor status. Secondary measures for functional status: King-Devick Test, Delis-Kaplan Executive Function System Trail Making Test: Condition 1 Visual Scanning, Modified Nelson-Denny Reading Test, and Subjective Vision Symptom Scale. RESULTS: Sixteen participants finished. Fatigue was the primary reason for withdrawal. No other negative effects were noted. Selected outcome measures captured positive improvements in both groups. CONCLUSIONS AND RELEVANCE: Study findings suggest conducting an appropriately powered RCT to evaluate efficacy of oculomotor treatment in this population. WHAT THIS ARTICLE ADDS: Oculomotor dysfunction seems to improve during inpatient TBI rehabilitation with remedial treatment. Best practice in occupational therapy has not yet been established. An appropriately powered RCT could positively contribute to the evidence available to clinicians.

The Craig Hospital Eye Evaluation Rating Scale (CHEERS).

BACKGROUND: Oculomotor deficits in smooth pursuit, saccades, vestibular-ocular reflex (VOR), vergence, and fixation are common problems seen after moderate to severe traumatic brain injury (TBI). No scale currently exists to rate all of these together. The Craig Hospital Eye Evaluation Rating Scale (CHEERS) was designed to systematically quantify frequency and severity of eye movement deficits in TBI. OBJECTIVE: To assess the intra- and interrater reliability of a new rating scale for detecting the presence and degree of 5 oculomotor abnormalities after TBI. DESIGN: A reliability study. SETTING: This was an institution-based study at Craig Rehabilitation Hospital. PARTICIPANTS: English-speaking patients between ages 18 and 65 years with a primary diagnosis of moderate to severe mechanical TBI and who were not blind in either eye were eligible. METHODS: Between October 2013 and March 2014, a total of 11 TBI patients and 9 non-TBI controls were enrolled in the study. The median age was 30 years (range, 18-74 years) for subjects and 52 years (range, 28-63 years) for controls. All patients were male, and 8 of 9 controls were female. Eye movements (fixation, smooth pursuit, saccade, convergence, and vestibular-ocular reflex) were recorded for each on digital video. They were rated on 2 separate occasions by each of the 2 raters. MAIN OUTCOME MEASUREMENTS: Inter- and intrarater reliability tests. RESULTS: Median elapsed time between the first and second ratings was 7 days (range, 5-44 days). Intrarater agreement was very strong (Spearman ρ ≥ 0.900) for pursuit, saccades, and VOR for both raters, and strong (Spearman ρ ≥ 0.710) for vergence and fixation. The interrater agreement for detecting presence of any oculomotor abnormality was substantial (unweighted κ = 0.63). The interrater concordance on the full range of scale scoring was strongest on the VOR test (weighted κ = 0.98), was substantial for vergence, pursuit, saccades, and total score (weighted κ > 0.60), and was moderate for fixation. For TBI patients, every eye movement rated was found to be more abnormal than compared to those in the controls. CONCLUSIONS: CHEERS is a reliable scale for assessing and quantifying oculomotor deficits commonly observed in moderate to severe TBI. Further studies to validate the scale's utility in outcome prediction, and its applicability to broader brain injury populations, are warranted. LEVEL OF EVIDENCE: IV.