Systematic Review Brief

Vestibulo-Ocular Interventions to
Support Occupational Performance for

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People With Traumatic Brain Injury With
Visual Symptoms (June 2013–October
2020)
Jennifer Kaldenberg, Robin Newman, Christine Jimenez, Mary Walker

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with
the American Occupational Therapy Association’s Evidence-Based Practice Program. Each Systematic Review
Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief
presents findings from the systematic review on the effectiveness of vestibulo-ocular interventions that address
visual impairments and visual perception to improve occupational performance for adults with traumatic brain injury.
Kaldenberg, J., Newman, R., Jimenez, C., & Walker, M. (2022). Systematic Review Brief—Vestibulo-ocular interventions to support occupational
performance for people with traumatic brain injury with visual symptoms (June 2013–October 2020). American Journal of Occupational Therapy,
76, 7613393070. https://doi.org/10.5014/ajot.2022/76S2007

Full Systematic Review Question Summary of Key Findings

his systematic review addressed the question Four articles representing 3 studies were included in the
T “What is the evidence for the effectiveness of inter-
ventions that address visual impairments and visual
review related to vestibulo-ocular interventions (Table 1).
The levels of evidence used in this review are from
perception to improve occupational performance for Oxford Centre for Evidence-Based Medicine (2009).
people with traumatic brain injury (TBI)?”

Bottom Line for Occupational

Current Theme Reported
The main theme of the studies included in this system-
atic review brief is vestibulo-ocular interventions.
Clinical Scenario
Traumatic brain injury (TBI) can have a significant im-
pact on the visual system leading to deficits in
visual field, visual acuity, oculomotor skills, and visual
processing abilities (Cockerham et al., 2009), with esti-
mates as high as 90% of all people with TBI
experiencing visual consequences (Jacobson & Marcus,
2011). Visual and visual perceptual deficits as a result of
TBI can significantly impact participation in meaningful
everyday activities (Greenwald et al., 2012; Kerkhoff,
2000). More specifically, vestibulo-ocular dysfunction
can have significant impact on occupational perfor-
mance as a result of dizziness, blurred vision, challenges
with balance, and nausea (Wallace & Lifshitz, 2016).
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Therapy Practice
The systematic review provides moderate level of
evidence to support the use of vestibulo-ocular inter-
ventions to minimize the visual symptoms associated
with vestibular dysfunction and low strength of evi-
dence to support the use of vestibulo-ocular
interventions to improve occupational performance in
people living with TBI. Three Level 3B studies support
the use of vestibulo-ocular interventions as a prepara-
tory method to minimize oculomotor symptoms in
people with visual impairments post TBI (Adams &
Moore, 2017; Carrick et al., 2019; Galey et al., 2020;
Kontos et al., 2018). The use of vestibulo-ocular inter-
ventions may facilitate occupational engagement in
occupations by reducing the symptom burden (e.g.,
dizziness and oculomotor symptoms) caused by TBI
(Adams & Moore, 2017; Carrick et al., 2019; Galey
et al., 2020; Kontos et al., 2018). Occupational therapy
1
Table 1. Evidence Table for Vestibulo-Ocular Interventions to Support Occupational Performance
Statistically Significant
Author/Level of Evidence Intervention Improvement From Intervention
Three Level 3B studies and one follow-up study implemented vestibular interventions to minimize the impact of oculomotor
disturbances on occupational performance in people living with TBI. Low strength of evidence supports the effectiveness of
this therapy.
Adams & Moore (2017) Population This intervention used RPQ (King
3B—Pre-Post test design Adults with postconcussive dizziness and et al., 1995) and DHI (Jacobson &
debility, N 5 6 Newman, 1990).

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Setting Statistically significant differences
Home based Intervention were found in the RPQ-3 (p 5 0026)
Multimodal rehabilitation program that and RPQ-13 (p 5 .037) and DHI
Country consisted of vestibular rehabilitation and a (p 5 .033) at 6-mo posttreatment.
USA combination of exercise, vision therapy,
physical therapy, neuropsychology, and
psychotherapy. Vestibular rehabilitation
included gaze stabilization, gait and
sensory organization and balance. Exercises
began in simple stable environments and
progressed to complex and dynamic
environments.

Delivery Method
Individual, supervised home program

Dose
Varied by intervention from 10 min daily to
30 min 3–5 times/day for a period of 6 mo
Carrick et al. (2019) Population Saccadic metrics
3B—Retrospective analysis Adults with postconcussive syndrome
(sports concussion) and mental health
Setting concerns (depression), >9 mo
Outpatient therapy postconcussion, N 5 6

Country Intervention
USA Primary treatment: gaze stabilization
exercise with coordinated HEVM at
positions and speed associated with a
decompensation of head and eye
movements.

Delivery Method
Individual

Dose
5×/day with minimum rest periods of 1.5
hr between sessions for 5 days for primary
treatment
Kontos et al. (2018) Population
3B—Pre/Post single group Adults with chronic, intractable, mTBI
(TEAM-TBI), N 5 26
Secondary follow-up analysis-dose:
Galey et al. (2020) Intervention
3B—Pre/Post single group Progressive, targeted, active interventions
that included: behavioral, vestibular, vision
Setting and exertion. Interventions were matched
Outpatient therapy to the participant’s clinical profile.
Interventions included: behavioral
Country interventions (prescribed reading and/or
USA screen usage) to home-based vision
exercises: convergence (i.e., Brock strings
and pencil pushups); saccade and pursuit
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The intervention groups showed
improved symptoms, verbal memory,
smooth pursuits, horizontal vestibular
ocular reflex, visual motion
sensitivity, convergence distance,
activity-specific balance confidence
and (2020) visual oculomotor vision
(vestibular and oculomotor symptoms)
(Kontos et al., 2018).
Follow up
Assessing the rate of compliance in
taking part in therapy, they found
high compliance (vs. low or
(Continued)
2
Table 1. Evidence Table for Vestibulo-Ocular Interventions to Support Occupational Performance (Cont.)
Statistically Significant
Author/Level of Evidence Intervention Improvement From Intervention
exercises; or computerized home vision moderate) with prescribed exertion/
program. vestibular rehabilitation therapies
enhanced clinical outcomes (Galey
Delivery Method et al., 2020).
Individual and remote monitoring via phone
and iPad

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Dose
Not reported, assessed 6 mo post
intervention/treatment

The levels of evidence used in this review are from Oxford Centre for Evidence-Based Medicine (2009).
Note. DHI 5 Dizziness Handicap Inventory; HEVM 5 head-eye vestibular motion; mTBI 5 mild traumatic brain injury; RPQ 5 Rivermead
Post-Concussion Symptoms Questionnaire.

practitioners should incorporate gaze stabilization, sen-
sory organization, and static/dynamic balance exercises
into rehabilitation for adults with TBI on a case-by-
case basis to manage/resolve visual symptoms. More
research is needed to demonstrate the impact of vesti-
bulo-ocular rehabilitation on functional-oriented
outcomes (i.e., activities of daily living and Berg
Balance Scale).
References
*Adams, J., & Moore, B. (2017). Return to meaningful activities after a
multi-modal rehabilitation programme among individuals who
experience persistent dizziness and debility longer than 9 months
after sustaining a concussion: A case series. Physiotherapy Canada,
69, 249–259. https://doi.org/10.3138/ptc.2015-81ep
*Carrick, F. R., Hankir, A., Zaman, R., Antonucci, M. M., Pagnacco, G.,
Azzolino, S., & Oggero, E. (2019). Improvement of saccadic eye
movements after head-eye vestibular motion (HEVM) therapy and
neuro-psychiatric considerations. Psychiatria Danubina, 31(Suppl 3),
318–323. https://europepmc.org/article/MED/3148874731488747
Cockerham, G. C., Goodrich, G. L., Weichel, E. D., Orcutt, J. C., Rizzo,
J. F., Bower, K. S., & Schuchard, R. A. (2009). Eye and visual function
in traumatic brain injury. Journal of Rehabilitation Research and
Development, 46, 811–818. https://doi.org/10.1682/JRRD.2008.08.0109
Galey, J. L., Eagle, S. R., Blaney, N. A., Holland, C. L., Bitzer, H. B.,
Schneider, W., … , Kontos, A. P. (2020). Effect of patient compliance
with treatment recommendations on clinical outcomes in chronic
mTBI: A TEAM-TBI study. Military Medicine, 185, e1229–e1234.
https://doi.org/10.1093/milmed/usaa025
Greenwald, B. D., Kapoor, N., & Singh, A. D. (2012). Visual impairments
in the first year after traumatic brain injury. Brain Injury, 26,
1338–1359. https://doi.org/10.3109/02699052.2012.706356
Jacobson, S., & Marcus, E. M. (2011). Neuroanatomy for the
neuroscientist (2nd ed.). Springer. https://link.springer.com/book/
10.1007/978-3-319-60187-8?noAccess=true
*Indicates articles included in the brief systematic review.
Jacobson, G. P., & Newman, C. W. (1990). The development of the
dizziness handicap inventory. Archives of Otolaryngology: Head and
Neck Surgery, 116, 424–427. https://doi.org/10.1001/archotol.
1990.01870040046011
Kerkhoff, G. (2000). Neurovisual rehabilitation: recent developments and
future directions. Journal of Neurology, Neurosurgery, and Psychiatry,
68, 691–706. https://doi.org/10.1136/jnnp.68.6.691
King, N. S., Crawford, S., Wenden, F. J., Moss, N. E., & Wade, D. T.
(1995). The Rivermead Post Concussion Symptoms Questionnaire: a
measure of symptoms commonly experienced after head injury and
its reliability. Journal of Neurology, 242, 587–592. https://doi.org/
10.1007/BF00868811
*Kontos, A. P., Collins, M. W., Holland, C. L., Reeves, V. L., Edelman,
K., Benso, S., … , Okonkwo, D. (2018). Preliminary evidence for
improvement in symptoms, cognitive, vestibular, and oculomotor
outcomes following targeted intervention with chronic mTBI
patients. Military Medicine, 183(suppl_1), 333–338. https://doi.org/
10.1093/milmed/usx172
Oxford Centre for Evidence-Based Medicine (2009). Levels of evidence
(March 2009). https://www.cebm.ox.ac.uk/resources/levels-
ofevidence/oxford-centre-for-evidence-based-medicine-levelsof-
evidence-march-2009
Wallace, B., & Lifshitz, J. (2016). Traumatic brain injury and vestibulo-
ocular function: current challenges and future prospects. Eye and
Brain, 8, 153–164. https://doi.org/10.2147/EB.S8267028539811
Jennifer Kaldenberg, DrPH, MSA, OTR/L, SCLV, FAOTA, is Interim OTD
Program Director and Clinical Associate Professor, Boston University
College of Health & Rehabilitation Sciences: Sargent College.
Robin Newman, OTD, MA, OTR/L, CLT, FAOTA, is Clinical Assistant
Professor, Boston University College of Health & Rehabilitation Sciences:
Sargent College.
Christine Jimenez, OTS, is a graduate student at Boston University
College of Health & Rehabilitation Sciences: Sargent College.
Mary Walker, OTS, is a graduate student at Boston University College of
Health & Rehabilitation Sciences: Sargent College.

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