A Letter of Understanding
For friends & family of patients

Dear Friends and Family,

I want to extend my heartfelt gratitude for your support and understanding as we navigate through the challenges faced by your loved one following their mild traumatic brain injury (mTBI).  Your unwavering care and dedication will make a remarkable difference in their journey toward recovery.

I understand that witnessing the functional difficulties your loved one is experiencing might be confusing, deeply concerning and perhaps even overwhelming at times.  As an optometrist trained to work with patients with brain injuries, I’ve had the privilege of working closely with patients suffering visual-vestibular mismatch (VVM), helping them and their families address their unique and specific challenges.

The impact of mTBI on one’s visual system can often be subtle yet profound, especially when a visual-vestibular mismatch is involved.  It may manifest in various ways that effect day-to-day activities, much like the challenges faced in managing a household.  Allow me to draw parallels between their visual difficulties and the relatable aspects of maintaining a home:  Just as maintaining a harmonious household requires seamless integration of various tasks, your loved one’s visual system faces hurdles in coordinating different sensory and motor neurological systems together to process, interpret and integrate visual information effectively.

For instance:

Balance and stability  

Imagine the effort involved in managing and coordinating multiple household tasks all at once.  Now add in some unexpected event or stressor, and consider how easy it is to re-juggle and maintain all household demands.   Physical balance and stability works similarly:

• Your loved one’s struggle with visual-vestibular integration dysfunction might affect their ability to maintain balance and stability, impacting how they navigate, stand, or move confidently
• You may notice your loved one standing in an unusual posture, swaying to one side when walking, bumping into furniture or doorframes, or needing to use a handrail when negotiating stairs
• Inclined or uneven surfaces suddenly become difficult to transverse, and you notice they are holding on to you for support when walking in busy environments, or when they are fatigued

Spatial awareness and navigation

Consider the importance of spatial awareness in organizing and maneuvering within your home or neighborhood:

• Visual-vestibular dysfunctions can impede their spatial perception, making it difficult to judge distances accurately or orient themselves in space, especially in new, unfamiliar or complex visual environments
• You may have noticed your loved one is clumsier or dis-coordinated, is dropping dishes more regularly, has burned themselves using the stove, or is covered in bruises 
• Travelling in a vehicle with them is challenging as they appear to misjudge space and time, and over-react to sensory stimulation (e.g. windshield wipers are bothersome, radio is too loud, stop-and-go traffic is making them sick)

Sensory integration

Much like the need to integrate different elements for smooth household management, your loved one might:

• Encounter difficulties in integrating visual and vestibular signals, leading to disequilibria, dizziness, sense of being unsteady, nausea, disorientation, anxiety and even detachment (not feeling like in one’s own body)  
• This is particularly provoked when exposed to busy, visually dynamic environments (e.g. grocery shopping, heavy traffic flow), doing repetitive physical movements (e.g. exercise, loading dishwasher, doing laundry), or is engaged in a cognitively-demanding or stressful situation

Coordination

Much like the need for coordination in managing household activities, your loved one may:

• Face challenges in their ability to smoothly track, gracefully move their eyes from one position to another, or coordinate the control of both eyes together 
• Failure to do so may result in blurry or double vision; eyestrain or eye fatigue; loss of spot, word or line omission, or re-reading; reliance upon using a finger or straight-edge to keep spot on page; or difficulty shifting visual attention from one spot to another 
• Entering your loved one’s peri-personal space unexpectedly (e.g. to give a hug) may even trigger an unintentional and visibly negative reaction from them

Visual fatigue

Just as one can feel exhausted after managing household responsibilities, your loved one might:

• Experience visual, cognitive, or physical fatigue quickly while engaging in visually demanding tasks due to the brain’s increase effort in processing visual information

Sensitivity to visual stimulation

Similar to adjusting to changes in household routine, your loved one may:

• Find it challenging to adapt and experience discomfort with changes in visual stimuli (e.g. light) or environmental conditions (e.g. visual motion) due to their compromised ability to process visual and vestibular information cohesively.  Indoor lighting may be too bright requiring lights to be turned off or blinds drawn
• Sunglasses may be worn to watch TV, look at their phone, or as an attempt to manage the overwhelming discomfort of oncoming car headlights at night
• Even changes in weather patterns have been known to provoke symptoms in some people

Sensitivity to auditory stimulation

Because a visual-vestibular mismatch can fundamentally interfere with your loved one’s interpretation of where they are in space, it may also similarly:

• Interfere with their ability to judge where sound is coming from
• Thus, problems with sound hypersensitivity, being able to concentrate on a single conversation in a noisy social situation, and tinnitus are also common in patients exhibiting a visual-vestibular dysfunction

Focusing and attention

Similar to the need for focus while managing multiple household chores, your loved one might:

• Face challenges in maintaining attention during specific visual tasks or in visual (and/or auditory) stimulating environments
• This might present as easily distracted or attention deficient behaviour, as an inability to multitask, or readily shift from one task to another 
• Alternatively, this may also initially present as a hyper-focused, tunnel-like behaviour and is generally followed by excessive fatigue, headaches or dizziness if this compensatory behaviour is sustained too long

Cognition and memory

Just like running a household requires planning and a good memory to remember birthday parties and bill payments, your loved will likely:

• Experience some difficulties with higher cognition functions (e.g. short term memory, name recall, multi-tasking, problem-solving, decision-making, and even verbal expression) as their cognitive resources are diverted to compensate for weaker and more basic neurological functions (e.g. sensory-motor integration) 
• This is probably most evident to you when your loved one is excessively fatigued, overwhelmed or stressed-out, and may impact their ability to process information, organize tasks, maintain focus, similar to managing multiple responsibilities at home

Sleep difficulties

Like the importance of a restful night’s sleep for a rejuvenated day at home, your loved one might:

• Encounter challenges with sleep patterns or insomnia following their injury
• These disturbances in sleep can affect overall well-being, energy levels, and cognitive functioning; and can impair recovery
• Pursuing restful and consistent sleep plays a very important role in your loved one’s rehabilitation journey

Anxiety and depression

Much like managing unexpected household disruptions, your loved one might:

• Experience heightened levels of anxiety due to perceived spatial uncertainties, and to uncertainties surrounding their condition, changes in routines, or difficulties in coping with everyday challenges post-injury
• Similar to the impact of a somber atmosphere at home, your loved one might experience sadness, hopelessness or a loss of interest in activities they once enjoyed
• These feelings of depression can affect their motivation, social interactions and overall quality of life

It’s important to emphasize that these challenges are a natural part of the recovery process.  With patience, specialized interdisciplinary care, and your incredible support, progress can be made to improve their visual function and overall well-being.

I want to assure you that our dedicated team is committed to providing the best possible care for your loved one.  We work diligently toward using tailored strategies, therapies, and interventions aimed at optimizing their visual abilities and enhancing their quality of life.

Your understanding, encouragement and ongoing support are invaluable in this journey.  Please know that your dedication plays an integral role in their recovery, and together, we will continue to make meaningful strides toward improvement.

Thank you once again for entrusting us with their care.  If you have any questions or concerns, please don’t hesitate to reach out.  Your involvement and care make a significant difference.  

With deepest gratitude,

Dr. Kevin Loopeker, OD, FOVDR