Phil Jones - Low Vision

COMMON APPLICATIONS
OF THE DYNAVISION D2™
FOR TREATMENT OF LOW VISION
Phil Jones
Founder and President
Jennifer Fortuna, MS, OTR/L
Business Training Coordinator
© 2015 Dynavision International, LLC

OVERVIEW
 Introduction
 Occupational Performance
 Applications
 Objectives
 Treatment Strategies
 Programmable Options
 Report Management
 Normative Data
 Modifications
 Tachistoscope
 Questions

INTRODUCTION
Originally developed for sports vision training of athletes, the
Dynavision D2™ has proven effective for use in visual, cognitive
and physical rehabilitation after brain injury and stroke (Akinwuntan
et al., 2008; Anderson et al., 2011; Klavora et al., 1995; Klavora et
al., 2000; Klavora & Warren, 1998; Vesia et al., 2008; Hunt, 2008).

INTRODUCTION
Operating System:
Adjustable light board (4’ x 4’ )
Wall or stand mount installation
Netbook interface
Auditory feedback
Game-like presentation
Printer (optional)

OCCUPATIONAL PERFORMANCE
Role of the Central Nervous System:
 Take in/process sensory stimuli from the environment
 Filter out irrelevant information
 Prioritize
 Adapt to change
 Regulate arousal levels
 Produce a behavioral response
According to Warren (1993) 90% of the information take in
from the environment comes from visual stimuli.
Occupational performance is dependent on the ability of the
CNS to process incoming visual stimuli from the environment.

Visual Input:
 Cognitive processing (visual cognition)
 Problem solving
 Decision making
 Motor control
 Ability to navigate static/dynamic environments
 Postural control
 Social interpretation
 Visual cognition builds the foundation for academics, leisure
activities and many vocations

Visual Impairment:
 Disease
 Trauma
 Age
Dysfunction:
 Influences cognitive processing
 Impairs problem solving and decision making
 Increases frustration and anxiety
 Reduces self-confidence and self-awareness
 Prevents the CNS from producing an adaptive response
 Negatively impacts participation in meaningful occupations

Warren’s Visual Perceptual Hierarchy (Warren, 1993)
 A visual perceptual hierarchy used to evaluate and treat
underlying visual deficits.
 Higher level skills evolve from integration of lower level skills.
All skills interact and are affected by disruption.

Warren’s Visual Perceptual Hierarchy (Warren, 1993)
 Identification and remediation of deficits in foundational skills
allows for normal integration of higher level skills.
 Visual processing builds the foundation for cognitive
processing. Altering vision will alter cognition.
 Highest level of visual integration is visual cognition.
“The ability to mentally manipulate visual information and
integrate it with other sensory information to solve problems,
formulate plans and make decisions” (Warren, 1993).

The Dynavision D2™ has been recognized as the premier
visual-motor reaction training system for over 25 years.
Programmable options standard with D2™ software enable the
clinician to facilitate individualized treatment programs for clients
of different ages, abilities, and conditions.

APPLICATIONS
The D2™ is utilized by a diverse group of medical professionals.
 Physical Therapy
 Occupational Therapy
 Speech Therapy
 Physiotherapy
 Optometry
 Neurology

APPLICATIONS
Visual Rehabilitation
 Visual reaction time
 Visual-motor integration
 Visual-perceptual processing
 Visual-spatial integration
 Visual processing speed
 Visual attention
 Visual memory
 Binocular vision
 Contrast sensitivity
 Central/peripheral visual integration
 Compensatory visual field training

APPLICATIONS
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

APPLICATIONS
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

OBJECTIVES
 Use visual dysfunction to explain functional limitations.
 Improve functional performance in meaningful occupations.
 Increase client insight into impact of visual impairment.

OBJECTIVES
Dysfunction:
 Identify and remediate deficits in lower level visual skills to
integrate higher level visual skills.
 Identify visual strengths to facilitate use of remaining vision.
 Link functional impairment to visual impairment.
 Help patient find new ways of completing meaningful activities
instead of giving them up.

OBJECTIVES
Functional Performance:
 Initiate wide head turns towards the affected visual field.
 Increase speed and accuracy of eye movements.
 Improve visual attention to detail and contrast.
 Shift attention between central and peripheral visual field.
 Incorporate body movements to improve vision and perception.

OBJECTIVES
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 and provide
opportunities use these strategies whenever possible.
 Verbal prompts:
 “Pay extra attention to the affected side,”
 “Where will I ask you to look?”
 “What part of this task did you find difficult?”

TREATMENT STRATEGIES
Determine current level of function
 Identify functional impairment
 Set the client up for success
 Avoid frustration
Utilize a vision screening tool such as the Colenbrander Low Vision
Measurement System.
 Letter chart for visual acuity down to 20/1000
 Reading cards with standardized paragraphs
 Mixed contrast cards for contrast sensitivity screening
Identify client’s own perceptions of visual challenges
 Reading
 Color recognition

 Activate the quadrant(s) on the D2™ that correspond with the
client’s strongest visual fields.
 Initiate saccadic training to help client compensate for field loss.
 Dim lights to help client locate the glow of red lights and direct
compensatory head movements.
 For patients with glaucoma, encourage use of functional vision to
compensate for loss of peripheral vision.
 Encourage wide head turns in the beginning. Gradually reduce
head movements to encourage a wider saccade.

Example:
Mode: Proactive (Mode A)
T-Scope: Off
Quadrants: Upper/lower left
Rings: All
Run 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

Clinical Observations
 Ability to initiate wide head turns toward affected side
 Ability to shift attention between visual fields
 Unsteady balance (seated and/or standing)
 Level of insight into impairments
Objective Data
 Score
 Average reaction time
 Significant differences in score/reaction time between quadrants
 Standing/seated activity tolerance

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

Rings
 Activate or deactivate the light board by individual rings

Quadrants
Activate or deactivate the light board by quadrant

 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)
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.

Reaction 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 visual motor baseline
 Monitor progress over time

Green 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. Score
2. Reaction Time
3. Results by Quadrant
4. 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

NORMATIVE DATA
Normative Data

MODIFICATIONS
Adjust for the client’s strengths/needs:
 Remove visual/auditory distractions
 Dim lights to increase contrast
 Adjust positioning/posture
 Consider “add-on’s”

MODIFICATIONS
Positioning:
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
 Left/right directionality
Picture Cards
 Visual field integration
 Sequential memory
 Divided attention
 Multi-tasking

TACHISTOSCOPE (T-SCOPE)
 Select from basic or advanced options

T-SCOPE
The T-Scope enables the clinician to grade visual and cognitive
demands quickly and easily.
Example: Three memory tests of graded complexity

T-SCOPE
Memory Test 1:
Step 1: Click Add Program
Step 2: Select Reactive Mode
Step 3: Activate rings 1, 2, and 3

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

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

T-SCOPE
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.
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

T-SCOPE
Memory Test 2:

T-SCOPE
Memory Test 2:
Step 7: Name the program Memory Test 2. Click OK.

T-SCOPE
Memory Test 2:
“Single digit 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.

T-SCOPE
Memory Test 3:

T-SCOPE
Memory Test 3:
Step 5: Under Lights/No Green Lights, click Change.
Select 20%.

T-SCOPE
Memory Test 3:
Name the program Memory Test 3. Click OK.

T-SCOPE
Memory Test 3:
“Single digit numbers will flash on the screen. Hit the red buttons as
quickly as you can. Call out the first number, remember the second
number, 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 D2™ is utilized by a diverse group of medical professions.
 Programmable options facilitate “just-right” challenges
appropriate for clients of various ages, stages, and conditions.
The applications are endless!
 The Dynavision D2™ increases insight into underlying deficits
and supports generalization of new skills into everyday life.
 D2™ software produces objective performance data to establish
accurate baseline measurements and monitor progress.
 Modifications facilitate creativity. Think outside of the box!

REFERENCES
Akinwuntan, A.E., Devos, H., Verheyden, G., Baten, G., Kiekens, C., Feys, H.,
& De Weerdt, W. (2010). Retraining moderately impaired stroke survivors in
driving-related visual attention skills. Topics in Stroke Rehabilitation, 17(5), 328-
336.
Anderson, 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.
Cole, M.B., & Tufano, R. (2008). Applied theories in occupational therapy.
Thorofare, NJ: SLACK Incorporated.
Colenbrander Low Vision Measurement System. (n.d.). Retrieved from
http://www.ski.org/Colenbrander/Images/LV_system.pdf

REFERENCES
Hunt, L.A., & Arbesman, M. (2008). Evidence-based and occupational
perspective of effective interventions for older clients that remediate or support
improved driving performance. American Journal of Occupational Therapy, 62,
136-148.
Klavora, P., Gaskovski, P., & Forsyth, R.D. (2000). Test-retest reliability of three
Dynavision tasks, Perceptual and Motor Skills, 80, 607-610.
Klavora, 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., Gaskovski, P., Heslegrave, R.J., Quinn, R.P. & Young, M. (1995).
Rehabilitation of visual skills using the Dynavision: a single case experimental
design. Canadian Journal of Occupational Therapy, 62, 37-43.
Toglia, J. & Abreau, B. (1987). Cognitive rehabilitation. New York, NY: Authors.

REFERENCES
Warren, 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.
Zoltan, B. (2007). Vision, perception, and cognition: A manual for the evaluation
and treatment of the adult with acquired brain injury (4th ed.). Thorofare, NJ:
SLACK Incorporated.

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