Ontario Neurotrauma Foundation

Clinical Practice Guideline

For the rehabilitation of Adults with Moderate to Severe TBI

Ontario Neurotrauma Foundation INESSS
SECTION 2: Assessment and Rehabilitation of Brain Injury Sequelae > N. Sensory Impairment

N. Sensory Impairment

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Traumatic brain injury (TBI) can result in sensory impairments affecting vision, perception, sensation and balance. Since many of these problems are not visible to the naked eye, persons with TBI should be screened systematically for these problems since they can severely limit their mobility and ability to function.

Individuals with TBI with any visual disturbances should be assessed by a team that includes an ophthalmologist and an orthoptist, where there are problems with eye movement/double vision. Professionals with expertise in rehabilitation for the visually impaired may be required to assist in treatment provision. Individuals with persistent dizziness should have access to an Otolaryngologiist specializing in vestibular dysfunction and vestibular testing. Vestibular rehabilitation therapists may be helpful for some people with TBI.


Indicators exemples

  • Proportion of individuals with TBI and visual disturbances assessed by at least two of the following professionals :

    • Ophthalmologists

    • Orthoptists

    • Professionals with expertise in rehabilitation for the visually impaired

The visual system is highly integrated with many functions other than simply sight, as it also acts as a primary sensory receptor for motor, social, cognitive, communicative, and emotive tasks. Improvements in visual-perceptual and visual-motor disorders can increase function in all the aforementioned areas and can enhance maximal functional recovery; therefore, individuals should be screened for visual impairment and/or perceptual deficits.

Visual dysfunction post acquired brain injury (ABI) can be corrected with base-in prisms, as they affect the ambient visual process by increasing the effectiveness of binocular cortical cells (Padula, Argyris, & Ray, 1994). Base-in prisms and bi-nasal occluders incorporated within the lenses of both eyes increase the amplitude of visual-evoked potentials (Padula et al., 1994). Prismatic spectacle lenses are also effective in reducing symptoms related to vertical heterophoria and concussion, as they reduce the faulty vertical alignment signal generated by the brain injury (Doble, Feinberg, Rosner, & Rosner, 2010).

Individuals with optic nerve or post-chiasmic injury associated with ABI who complete computer-based  Visual Restitution Training (VRT) experience visual field enlargement and increased light detection (Kasten, Wust, Behrens-Baumann, & Sabel, 1998). Detection training has shown improvements in visual detection, as well as improvements in other visual functions such as shape and color recognition (Kasten et al., 1998). When the reading dysfunction post-ABI is a result of sensory-based hemifield deficits or neuromotor deficits, saccadic oculomotor rehabilitation can lead to improvements in eye movements which are required for accurate reading (Ciuffreda, Han, Kapoor, & Ficarra, 2006). Repetitive oculomotor conditioning reduces the cognitive and attentional load of reading and results in a structural and systematic approach to reading. The benefits of oculomotor rehabilitation were observed in other ADLs such as concentration and visual scanning. Most importantly, reducing visual deficits in patients’ post-TBI may facilitate their involvement in other therapies and contribute to overall recovery (Ciuffreda et al., 2006).

Vestibular dysfunction is commonly overlooked when diagnosing an individual with TBI. When vestibular dysfunction is found, techniques typically used in vestibular rehabilitation are gaze stability exercises, vestibulo-ocular reflex gain adaptation, substitution exercises, habituation techniques and static and dynamic balance and gait exercises (Scherer & Schubert, 2009). In a small sample of adults, aerobic dancing and slide-and-step training improved balance and coordination in patients many years following TBI, suggesting that long-term improvement of vestibular dysfunction is possible with the appropriate program (Dault & Dugas, 2002). Further, (Gurr & Moffat, 2001) added a cognitive aspect to vestibular rehabilitation and found the multidimensional psychological approach was effective in improving vertigo symptoms, handicap, emotional distress, physical flexibility and postural stability (Gurr & Moffat, 2001).

Ciuffreda, K. J., Han, Y., Kapoor, N., & Ficarra, A. P. (2006). Oculomotor rehabilitation for reading in acquired brain injury. NeuroRehabilitation, 21(1), 9-21.

Dault, M. C., & Dugas, C. (2002). Evaluation of a specific balance and coordination programme for individuals with a traumatic brain injury. Brain Inj, 16(3), 231-244.

Doble, J. E., Feinberg, D. L., Rosner, M. S., & Rosner, A. J. (2010). Identification of binocular vision dysfunction (vertical heterophoria) in traumatic brain injury patients and effects of individualized prismatic spectacle lenses in the treatment of postconcussive symptoms: a retrospective analysis. Pm r, 2(4), 244-253.

Evidence-Based Review of Moderate To Severe Acquired Brain Injury (ERABI). (2016). http://www.abiebr.com/.  

Gurr, B., & Moffat, N. (2001). The effectiveness of cognitive-behavioural therapy for post-traumatic headaches. Brain Inj, 15(5), 387-400.

Kasten, E., Wust, S., Behrens-Baumann, W., & Sabel, B. A. (1998). Computer-based training for the treatment of partial blindness. Nat Med, 4(9), 1083-1087.

Padula, W. V., Argyris, S., & Ray, J. (1994). Visual evoked potentials (VEP) evaluating treatment for post-trauma vision syndrome (PTVS) in patients with traumatic brain injuries (TBI). Brain Inj, 8(2), 125-133.

Scherer, M. R., & Schubert, M. C. (2009). Traumatic brain injury and vestibular pathology as a comorbidity after blast exposure. Phys Ther, 89(9), 980-992.

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N1. Vision Assessment

P Priority F Fundamental New Level of evidence A B C
N 1.1 C

Individuals with traumatic brain injury should be screened for visual impairment and/or perceptual deficits and, if present, should undergo rehabilitation to address the specific visual impairment/deficit.

(Adapted from ABIKUS 2007, G55, p. 25)

N 1.2 P C

Individuals with traumatic brain injury with any visual impairment/deficit should be assessed by a team which includes, but is not limited to:

  • Ophthalmologists

  • Orthoptists where there are problems with eye movement/double vision

  • Professionals with expertise in rehabilitation for the visually impaired

(Adapted from NZGG 2006, 6.1.4, p. 95)

N2. Management of Vision Impairment

P Priority F Fundamental New Level of evidence A B C
N 2.1 P C

All individuals with traumatic brain injury who present with persistent visual neglect or field defects should be offered specific retraining strategies.

(Adapted from NZGG 2006, 6.1.4, p. 95)

N 2.2 C

Visual feedback force training should be used with individuals with traumatic brain injury who present tracking and transfer deficits.

(INESSS-ONF, 2015)


- ERABI Module 4- Motor & Sensory Impairment Remediation, p.11, 4.1.3

N3. Assessment of Vestibular Function

P Priority F Fundamental New Level of evidence A B C
N 3.1 B

Individuals with traumatic brain injury should be screened, and if needed, formally assessed for vestibular dysfunction and, if present, should undergo a vestibular retraining program. The screening should be conducted by a professional specializing in vestibular function.

(Adapted from ABIKUS 2007, G59, p. 25)

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