Tag Archives: visual

Left Neglect vs. Field Cut

It is possible for multiple distinct symptoms of an acquired brain injury to present in remarkably similar fashions.  For instance, a brain-injured survivor’s failure to take medication could be due to a memory deficit leading that survivor to simply forget his or her medication or it could be due to an attention deficit leading the survivor to be too distracted to take the medication in question.  In each case the medication was missed, but for acutely separate reasons.  A similar issue comes to light in observation of post-injury visual deficits.  Did a survivor fail to notice information to his or her left due to left neglect or due to a field cut?

Let’s start off with outlining precisely what a field cut is, as it is the simpler of the two to understand.  Under the effects of a field cut, the survivor has actually permanently lost the ability to perceive a portion of the field of vision.  That area of the field formerly available has now been “cut” away.  Due to his or her injury, the survivor is now in effect partially blind.  In medical terms, this loss of vision is often called “hemianopsia.”  So a survivor contending with a field cut has had actual visual loss  in his or her left visual field and thereby misses seeing information on his or her left side.

Left neglect is an attention issue which often manifests in the visual attention domain.  It is associated with an injury to the right side of the brain.  With left neglect, the brain fails to pay attention to information to the left side of the survivor.  If you ask a survivor with left neglect to turn his or her head all the way to the right, he or she will generally turn until the chin reaches the right shoulder.  However if you ask the same survivor to turn to the left, he or she may only bring the chin half-way to the the left shoulder despite fully understanding the request and giving a best effort to fulfill it.  It is almost as if the survivor’s brain is saying, “the left side of the world does not exist.”  The survivor’s eyesight can be perfectly intact, yet his or her brain is ignoring information generated from the left side.  This ignoring is not voluntary; as far as the survivor is consciously aware, he or she did look all the way to the left even though an outside observer can clearly see that the survivor did not make it all the way over.  Again, though it appears functionally as if the survivor has lost vision, the underlying issue is one of attention.

In the case of a field cut, most survivors do reasonably well after becoming sufficiently aware of their field cuts.  They will after enough practice naturally turn and make that extra effort to look for the information in their blind spots.  For a survivor with left neglect, improvement requires not just awareness but also daily repetition of scanning exercises and consistent use of visual aids.  As example, a survivor with left neglect may practice scanning techniques by slowly looking for information on a piece of paper being sure to start all the way on the left of that page before scanning across.  It can also be helpful to put a brightly colored highlighter mark on the paper to identify the far left of the page.  Sadly, in some cases a survivor will suffer from both left neglect and a field cut.  This combination can of course make successful functioning especially difficult, but with appropriate dedication and determined effort most any such goal gains entrance into the realm of the attainable.

I hope this clarifies the differences between left neglect and a field cut.  Please leave me a comment below with any questions, thoughts or ideas!

Learn about brain injury treatment services at the Transitional Learning Center!  Visit us at: tlcrehab.org

Visual Scanning with Telephone Books and Circulars

As I have talked about previously in this blog, many brain injury survivors recovering from traumatic brain injuries will experience visual scanning difficulties as a result of those injuries.  This can be due to a direct loss of visual ability (often called a visual field cut) or due to an attentional issue such as left neglect.  One convenient and practical way to work on scanning is for the survivor to practice with a telephone book or supermarket circular.

The idea is pretty straightforward:  the survivor is tasked with locating various items found in the advertisements of the telephone book’s yellow pages or in a supermarket circular.  You’ll want to pick items in a random order so as to prevent the survivor from figuring out where each correct item is without really working on the skills.  For example, if you are using restaurant ads in the yellow pages, you may first have the survivor find the hours of operation from an Arby’s ad in the top left corner, then the address of a Taco Bell advertised on the bottom left of the page, followed by the Domino’s Pizza fax number down at the bottom right. The supermarket circular can be used in the exact same manner.  As example, you could ask the survivor for the cost of the Oscar Meyer bologna in the top right corner of the page, then the size packaging of the Frosted Flakes cereal in the bottom left corner, followed by having the survivor point to the Hebrew National hot dogs back up towards the top right.

You do not want to tell the survivor where on the page each item is located, but allow the survivor to naturally search on his or her own.  All parts of the page, including the center, should be used during this activity.  If the survivor cannot find the material, the survivor (often with the help of a loved one) should be prompted to conduct a slow, organized search for the item in question.  If the survivor has left neglect, such a search should always begin on the left side, using a slow up-down search rather than side to side.  If the survivor has a visual field cut, the search should always begin on whichever side has suffered the cut, again using an up-down search.  If the survivor is missing the right visual field in both eyes, the search should always begin on the right side and if he or she is missing the left visual field in both eyes, the search should always begin on the left. Missing both the right or both the left visual fields is known as homonymous hemianopsia.

There are a few things you want to keep in mind to help this task go smoothly.  You will want to check and ensure that the information can be easily seen by the survivor.  Sometimes the writing in phone books and circulars may be quite small and the survivor may need to use reading glasses or perhaps need only to work with the bigger items on the page.  When working with the yellow pages, it is generally better to pick pages with lots of display ads rather than just listings.  I do not advise using the white pages since the writing is small, placed very close together and is always in an obvious alphabetical order.  Supermarket circulars are generally much better for this task than department store circulars since they will tend to list more items.  If the survivor has left neglect, it may be helpful to highlight the left side of the page or put a bright object (such as a strip of paper) on the left side.  Additionally, some survivors benefit from the use of a line reader (such as ruler) to help with their ability to focus on one section of information at a time.

Here are a few previous blog posts on home-based visual scanning activities:

https://tlcrehab.wordpress.com/2012/08/06/ispy/

https://tlcrehab.wordpress.com/2012/08/02/visual-scanning-practice-2/

Learn about brain injury treatment services at the Transitional Learning Center:
tlcrehab.org

Visual and Verbal Memory

Most information that we try to remember usually comes through only two of our five senses, vision and hearing.  Interestingly, the memories we make for this information is generally stored in two separate parts of our brain.  We tend to store verbal memories from the information that we heard in the left side of the brain.  We tend to store visual memories from the information that we saw in the right side of the brain.  One way that we can help our memory is by using both sides of our brain during memory tasks.

We can help our verbal memory by taking the information that we hear and creating pictures in our mind  of the information.  For instance, you might be told three items you need to buy in the store.  While trying to remember the words, you can imagine what those three items look like while sitting in your shopping cart.  In this way you both have verbal memories from when you heard the items told to you and visual memories from imagining yourself with those items in your cart.  Similarly, you can bolster your visual memory with your verbal memory.  For instance, you could try to remember where you parked your car at a store and at the same time you were visually looking at the parking spot, you could also verbally describe to yourself where you were parked.  In this example, you might look at the spot while telling yourself, “I am parked by the red pole, two spaces from the large concrete block.”  Your sight would provide the visual memory and the words would add  the verbal memory.  In these ways, both sides of your brain can be involved in helping you to remember information.  The more places you have information stored in your brain, the more easily you can later access that information.

Learn about brain injury treatment services at the Transitional Learning Center: tlcrehab.org

Can I Drive Yet?

One of the most common questions a patient will ask the Transitional Learning Center staff is when that patient will be able to resume driving.  This is an understandable concern as most Americans use their cars as their primary means of travel.  Additionally, a car is often viewed as a symbol of freedom and independence and not being able to drive is often felt as an acute personal loss.

Of all the activities of daily living, driving is one of the most complex and as such is uniquely susceptible to being effected adversely by deficits left in the wake of a brain injury.  Driving requires such skills as good vision to be able to adequately see traffic and other surroundings, solid motor coordination to operate the vehicle safely, strong attention skills to enable sufficient observation and anticipation of traffic and excellent reasoning skills to make safe decisions.  It requires strong memory skills in order to recall new directions as given and strong processing skills to analyze all of the various forms of information the driver receives in the course of a trip.

If all this were not difficult enough, driving requires all of these activities to be done while travelling at incredibly high rates of speed.  For instance, 60 miles per hour (a pretty typical speed limit for highways) is the equivalent of 88 feet per second!  Brain injury deficits are typically magnified by the speed with which a person is trying to do a given task, so the chance of making an error when driving is much greater than the chance of error while walking.  Moreover, making a mistake in a vehicle can be a much bigger problem because a  vehicle can weigh from between around 3000 pounds for a small compact car  to the neighborhood of 12,000 pounds for a larger truck.  If you are driving a midsize sedan at the highway speed limit, you are driving a vehicle weighing approximately 5500 pounds at 88 feet per second.  Any accident may be a major accident.

One of the statements we often hear from patients when discussing driving is, “But I haven’t forgotten how to drive.”  This may well be the case.  Unfortunately, this fact does little to lessen the gravity of the central issue at question.  Remembering or not remembering how to drive is not the problem.  Most patients in the post-acute stage of traumatic brain injury retain their pre-injury memories for how to engage in a number of activities, particularly those activities which have been done repeatedly like driving.   The issue is not whether or not a patient remembers how to drive, but to what extent that patient can safely drive today in spite of any deficits that may have been incurred due to his or her injury.

It is recommended that any person who has suffered a serious brain injury be evaluated by a driving rehabilitation professional prior to resuming driving.  Some brain injury survivors are able to return to driving but many cannot.  A professional evaluation will assess a patient’s driving skills to ensure both the safety of the survivor and of the public.  They also can and do recommend devices that may compensate for deficits.

Learn about brain injury treatment services at the Transitional Learning Center: tlcrehab.org

Making Windows Easier

There are a few tricks to making life on a computer easier after a brain injury.  One trick will work on most Windows based computers/programs and helps to remedy problems caused by vision deficits.  To increase the size of items on your computer’s display, simply click the mouse so the cursor is somewhere on the screen and then hold down the Control key while rolling forward the scroll wheel on top of the mouse.  This will allow you to greatly increase the size of items shown on your computer’s monitor.  For instance, I can increase the size of icons on my computer’s desktop from roughly 1 square inch to 4 square inches with this simple method.  To shrink enlarged items, simply follow the above instructions but roll the wheel backwards.  This method works on diverse programs such as Internet Explorer and all Microsoft Office applications but does not cause any kind of damage or permanent changes to work being done in those programs.  I hope this little trick can help you or a loved one make computer use more pleasant if this is a problem that’s been encountered.

Learn about brain injury treatment services at the Transitional Learning Center: tlcrehab.org 

Teacher Supply Stores

Many brain injury survivors and their families wonder about where they can find useful activities to improve the deficits left in the wake of a brain injury.  A favorite place of mine to find these types of activities is the teacher supply store.  You do not need to be a teacher to shop at one of these stores.

Teachers will work on skills such as reading, memory, perception and problem-solving.  All of these may be skills that a brain injury survivor needs to work on.  For instance, teacher supply stores have story cards to  practice memory, photograph libraries to practice naming and puzzles to practice visual-spatial skills.  The first time you go to one of these stores you will want to spend some time walking through the aisles and familiarizing yourself with all of the available selections as the inventory there is generally quite different from that of a typical retail store.  Every city with a reasonably sized population will have at least one of these stores.  In my experience, every store will have the same type of core material but some stores tend to specialize and may have particular items that other stores may miss.  The prices at these stores are usually pretty reasonable so you can often get some great activities under a more limited budget.

Learn about brain injury treatment services at the Transitional Learning Center: tlcrehab.org

Visual Scanning Skills With I Spy

As I stated in a previous post, many people with brain injuries have visual scanning deficits.  Often this is due to an injury to the right side of the brain.  An easy (and free) way to practice visual scanning skills is through an adaptation of the game I Spy.

The adapted version of I Spy is a very simple game to play.  At least two people are needed to play.  To start, pick a location or room with lots of items to see but which is not so familiar that everyone knows the location of all the items by heart.  One person is the “spy” and has to find an item that is visible to everyone.  The spy then says “I spy with my little eye ____ (the item).”  It is the job of the other players to point to the item to show that they have found it.

When I Spy is used to practice scanning skills after a brain injury, it is important to vary the location of the items that are being “spied.”  For instance, you may first want to “spy” an item on the right side and then an item on the left side.  Varying locations forces a person to scan the entire visual field.  If this game is being played with someone in a wheelchair, make sure that each item can be seen from his or her visual perspective.  Often items that are easy to see when standing are obstructed when sitting.  Also, make sure that the item is big enough to be clearly seen by all the players.  Sometimes a person with a brain injury loses some of their visual acuity due to the effects of the injury and may not be able to clearly see  small items.  If the person playing has left neglect, they will likely need extra help and direction to scan the left side of the visual field.

I Spy is an easy, portable method to practice visual scanning skills while still having fun!

Learn about brain injury treatment services at the Transitional Learning Center: tlcrehab.org

Visual Scanning Practice With Hidden Pictures

Many brain injured patients have difficulty with scanning skills.  This can be due to many problems such as partial loss of vision, left neglect  or visual-spatial deficits.  Often, but not exclusively, these problems are associated with an injury to the right side of the brain.

One way to practice scanning skills is by using hidden pictures puzzles.  Many people are familiar with hidden pictures puzzles from children’s magazines.  They involve a larger picture having many smaller items hidden within it.  The goal is to locate the smaller hidden items.   Highlights magazine has a number of free hidden pictures puzzles that can be printed from their online website:

http://www.highlightsteachers.com/teachers-toolbox/hidden-pictures

Although this is a fun way to practice scanning skills, it can be quite difficult and some individuals may need help from loved ones to work on these puzzles.

Learn about brain injury treatment services at the Transitional Learning Center: tlcrehab.org