Dynavision D2 for Rehab

COMMON APPLICATIONS AND PATIENT INDICATIONS FOR THE DYNAVISION D2™

IN CLINICAL REHABILITATION

Phil Jones Founder and President

Jennifer Fortuna, MS, OTR/LBusiness Training Coordinator

© 2015 Dynavision International, LLC

OVERVIEW


INTRODUCTION Theoretical Principles Operating System Programmable Options Data Management

PRACTICAL

ASSESSMENT AND TRAINING Clinical Applications Modifications

PRACTICAL

TEAM ACTIVITY

INTRODUCTION Theoretical Principles

Operating System

Programmable Options

Report Management

INTRODUCTION


Originally developed for sports vision training of athletes, the Dynavision D2™ has proven effective for use in visual, cognitive and physical rehabilitation; driver retraining; concussion baseline testing; and concussion management (Anderson et al., 2011; Klavora, Heslegrave, & Young, 2000; Wells et al., 2014; Klavora, & Leung, 1996; Clark et al., 2014).

THEORETICAL PRINCIPLES


Dynamic Interactional Approach (Toglia, 2005)

Focus: Restore functional performance for clients with cognitive dysfunction due to brain injury or developmental disability.

Applications: Metacognition, executive function, problem solving, attention, visual processing, motor planning, and effort.

Treatment: Self-awareness develops within the context of engagement, cues and strategies applied by therapist.

Transfer of Learning: Skills improve through practice on a cognitive continuum.



Person-Environment-Occupation-Performance (PEOP) (Christiansen & Baum, 2005; Law et al., 1996)

Focus: Occupations (valued roles, tasks, activities) and functional performance as selected by the client.

Applications: Intrinsic physiological, psychological, cognitive, neurobehavioral and spiritual factors impacting performance.

Treatment: Adapt the task to match the client’s abilities (intrinsic factors). Facilitate client’s ability to control movement, modulate sensory input, integrate sensory information, compensate for sensory deficits, and modify neural structures.

Transfer of Learning: A sense of accomplishment will create a reinforcing positive cycle of intrinsic and extrinsic reward.



Neurodevelopmental Treatment (NDT) (Bobath, 1950)

Goal: Client-centered, hands-on, problems solving approach used to manage and treat clients with CNS pathophysiology.

Applications: Balance, postural control, movement, mobility, proprioception/vestibular, weight bearing, vision and developmental disability.

Treatment: Therapist uses his or her own body to promote efficient movement and avoid unwanted motor responses

Transfer of Learning: Underlying deficits gradually improve over time as a result of skilled handling and neuroplasticity.



Warren’s Theory of Visual Development (Warren, 1993)

Focus: A hierarchy of visual processes used to identify the cause of underlying visual deficits.

Performance: All levels must work together. Foundational weakness affects function at all levels.

Transfer of Learning: Oculomotor control, central/peripheral visual fields and visual acuity lay the foundation for higher visual skills.

OPERATING SYSTEM


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

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


PROGRAMMABLE OPTIONS

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)Position the patient 6 feet from the D2™. 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 a 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

REPORT MANAGEMENT


Normative Data

REPORT MANAGEMENT


Normative Data

PRACTICALFrom Theory to Practice

Programmable Options

Report Management

FROM THEORY TO PRACTICE


NDT Principles and the Dynavision D2™

Patient:A 67-year-old female,12 weeks post right hemispheric cerebrovascular accident (CVA). Residual effects include left side hemiparesis, left visual unilateral inattention, flexor tone in the left upper extremity and poor standing balance.

Treatment:Use the D2™ as a preparatory intervention to improve upper extremity range of motion, standing activity tolerance, bilateral coordination and visual awareness of the neglected side.




Objectives:• Use therapeutic handling to increase access, promote efficient

movement and block unwanted motor responses.

• Combine weight-bearing with reach outside base of support to encourage active extension of the upper extremity for balance.

• Address visual deficits through use of auditory and tactile input to retrain vision through association.

• Incorporate clinical observations and objective data into notes.




The client is seated within arm’s length of the light board. Therapist is seated on the client’s affected side. Therapist blocks clients affected leg at the knee and shin.




Therapist facilitates safe sit to stand. Therapist provides support at the trunk and clavicle.




Therapist stabilizes affected arm in weight bearing. The client reaches and strikes targets with unaffected arm. Therapist supports weight shifts to/from affected side.




Programming:Mode: Proactive (Mode A)T-Scope: OffQuadrants: AllRings: 1-3 activatedRun Time: 30 seconds

Suggested Instructions:“When a flashing red light appears, hit it as fast as you can. Keep hitting the red lights until the run is over.” f

DATA MANAGEMENT


Clinical Observations Unsteady balance (seated and/or standing) Pauses before striking buttons Level of physical assistance to complete task Eye-hand coordination

Objective Data• Score• Average reaction time• Significant differences in score/reaction time demonstrating

visual neglect/awareness of affected side• Standing/seated activity tolerance



Dynamic Interactional Approach

Saccadic training is usually the first step in helping a patient with hemianopsia compensate for visual field loss.

With lights dimmed, the patient should be able to locate the glow of the red light to direct compensatory head movements.

In the beginning, encourage wide head movements. As the patient becomes comfortable with the task gradually reduce the head movement to encourage a wider saccade.



Tips to Increase Client 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. Provide opportunities use these strategies whenever possible.

Use verbal cues to increase insight. “Pay extra attention to the affected side,” “Where will I ask you to look?” “What part of this task did you find difficult?”



Dynamic Interactional Approach and the Dynavision D2™

Objectives: Initiate wide head turns towards the affected visual field. Increase speed and accuracy of eye movements. Improve visual attention to detail. Quickly shift attention between the central visual field and

peripheral visual field. Incorporate body movements to improve vision and perception. Increase insight into how the visual impairment impacts function.



Dynamic Interactional Approach and the Dynavision D2™

Programming: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

DATA MANAGEMENT


Clinical Observations Ability to initiate wide head turns toward affected side Client’s ability to shift attention between visual fields Unsteady balance (seated and/or standing) Client’s level of insight into impairments

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

ASSESSMENT & TRAININGClinical Applications

Modifications

CLINICAL APPLICATIONS


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



The Dynavision D2™ has been recognized as the premier visual-motor reaction training system for over 25 years. Currently the D2™ utilized by a variety of medical professions.

Physical Therapy Occupational Therapy Speech Therapy Optometry Neurology



Visual Rehabilitation

Visual reaction time Visual-motor integration Visual-perceptual processing Visual-spatial integration Visual processing speed Visual attention Visual memory Binocular vision Integrate central/peripheral vision Compensatory training strategy for visual field deficits



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



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

MODIFICATIONSAdjust for the patient’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

• Picture Cards• Sequential memory • Divided attention • Multi-tasking


PRACTICALConcussion Baseline Test and Exam

Key Points

CONCUSSION BASELINE TEST


1. Proactive (Mode A)2. Reaction Test (Mode D)

Programs come standard with D2™ software.

CONCUSSION BASELINE TESTProactive (Mode A)Step 1: Click *Proactive, 1 minStep 2: Click Run Program


CONCUSSION EXAM


Verbal Instructions: “Hit the red buttons as quickly as you can until time runs out.”

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

CONCUSSION EXAM


Data Management: Note the client’s average reaction time and clinical observations.

CONCUSSION BASELINE TESTReaction Test (Mode D):Step 1: Click *Reaction TestStep 2: Click Run Program


CONCUSSION EXAM


The Reaction Test consists of 6 tests: 3 for the right hand 3 for the left hand

Verbal Instructions: “Press and hold the red button. When a second red light appears strike it as quickly as you can.”




Reaction Test (Mode D):

Test 1: Right Hand – 4 Choice




Test 2: Left Hand – 4 Choice



















Data Management: A text report will appear at the conclusion of the sixth and final reaction test. Visual, Motor, and Physical reaction times, number of attempts and number of false starts are indicated.



To Calculate Score:

1. Add the total number of hits and the T-Scope score.

2. Subtract the number of errors.

3. Multiply this number by two to determine the final score.

Example:

Number of hits 38T-Scope Score +8 Errors -2 Final Score = 44

44 X 2 = 88

Baseline Score = 88



Score Interpretation:

A less than 10% reduction in baseline score at retest indicates a passing score.

A 10% reduction in baseline score at retest indicates a failing score.

CONCUSSION EXAM


1. Memory Test 12. Memory Test 23. Memory Test 3

Programs are created by the clinician and saved in program history.

CONCUSSION EXAM


Memory Test 1:

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



Memory Test 1:

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



Memory Test 1:

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

CONCUSSION EXAM


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.


CONCUSSION EXAM


Memory Test 2:


CONCUSSION EXAM


Memory Test 2:


CONCUSSION EXAM


Memory Test 2:

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

CONCUSSION EXAM


Memory Test 2:

Verbal Instructions: “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.


CONCUSSION EXAM


Memory Test 3:


CONCUSSION EXAM


Memory Test 3:


CONCUSSION EXAM


Memory Test 3:

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

CONCUSSION EXAM


Memory Test 3:

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

CONCUSSION EXAM


Memory Test 3:

Verbal Instructions: “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. 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 Dynavision D2™ increases insight into underlying deficits

and supports generalization of new skills into everyday life.

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

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

The D2™ is fun! Tapping into the patient’s intrinsic motivation makes participation rewarding in-and-of itself.


QUESTIONS?

TEAM ACTIVITY

REFERENCESAnderson, 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.

Bobath, B. (1990). Adult hemiplegia: Evaluation and treatment (3rd ed.). London, UK: Heinemann.

Christiansen, C., & Baum, C. M. (2005). Occupational therapy: Enabling function and well-being (3rd ed.). Thorofare, NJ: SLACK Incorporated.

Clark, J.F., Graman, P., Ellis, J.K., Mangine, R.E., Rauch, J.T., Bixenmann, B., Hasselfeld, K.A., Divine, J.G., Colosimo, A.J., & Myer, G.D. (2014). An Exploratory study of the potential side effects of vision training on concussion incidence in football. In press.

Cozolino, L. & Sprokay, S. (2006). Neuroscience and adult learning. New Directions for Adult Learning and Continuing Education, 110, 11-19.

REFERENCESKlavora, 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., & Leung, M. (1996). Case study I. In P. Klavora & M. Warren (Eds.), Dynavision for rehabilitation of visual and motor deficits: A user’s guide. Lenexa, KS: visAbilities Rehab Services, Inc.

Law, M., Cooper, B., Strong, S., Steward, D., Rigby, R., & Letts, L. (1996). The person-environment-occupation model: A trans-active approach to occupational performance. Canadian Journal of Occupational Therapy, 63, 9-23.

Toglia, J. (2003). Multicontext treatment approach. In E. Creapeau, E. Cohn, & B. Boyt Schell (Eds.), Willard and Spackman’s occupational therapy. Philadelphia, PA: Lippincott, Williams & Wilkins.

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.

Wells, A.J., Hoffman, J.R., Beyer, K.S., Jajtner, A.R., Gonzalez, A.M., Townsend, J.R., Mangine, G.R., Robinson, E.H., McCormack, W.P., Fragala, M.S., & Stout, J.R. (2014). Reliability of the Dynavision D2 for assessing reaction time performance. Journal of Sports Science and Medicine, 13, 145-150.

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Dynavision D2 for Rehab