A PT's Guide to Vision Therapy for Post-TBI Visual Dysfunction

Many patients with TBI experience debilitating visual symptoms. This brief provides a practical guide to vision therapy, a targeted approach to retraining the visual system, improving oculomotor control, and getting your patients back to their lives.

Research: April 2026

The Brock String exercise is a fundamental tool in vision therapy used to improve binocular vision and vergence skills by providing immediate feedback on eye teaming.

Key Findings

1Restitutive vision therapy shows a trend toward improving oculomotor deficits in adults with mild TBI.
2Effective vision therapy is individualized and targets specific deficits like saccades, pursuits, and vergence.
3A combination of in-office therapy and home exercises is crucial for optimal outcomes.
4The overall certainty of evidence is still low, highlighting the need for more high-quality research in this area.

After a TBI, it's not uncommon for patients to complain of blurred vision, difficulty reading, or feeling overwhelmed in busy environments. These are often signs of visual dysfunction, and vision therapy can be a game-changer. It's an active, non-invasive approach that uses specific exercises to retrain the brain and eyes to work together more efficiently. Think of it as physical therapy for the visual system. A 2024 systematic review and meta-analysis by Biscardi et al. looked at 12 studies and found a promising trend toward improvement in oculomotor deficits with restitutive interventions. The most effective programs are individualized and often include exercises targeting saccades (quick eye movements), pursuits (smooth tracking), and vergence (eye teaming). For example, you might have a patient follow a moving target with their eyes (pursuits) or rapidly shift their gaze between two points (saccades). A typical protocol might involve in-office sessions once or twice a week for 8-12 weeks, supplemented with daily home exercises. The key is consistency and repetition to drive neuroplastic changes. While the evidence is still evolving, vision therapy offers a structured way to address these frustrating visual symptoms and can significantly improve a patient's quality of life.

Clinician's Note

In my experience, vision therapy is a powerful tool, but it's not a magic bullet. It's most effective when integrated into a comprehensive rehab plan that addresses other post-TBI symptoms. What the textbooks don't always emphasize is the importance of a multidisciplinary approach. I always co-manage these cases with a neuro-optometrist. They can do a more in-depth assessment of the visual system and rule out any underlying ocular health issues. Also, be prepared to manage patient expectations. Progress can be slow, and some patients may feel frustrated initially. It's our job to educate them about the process and celebrate the small wins along the way.

Clinic Action Plan

1. Patient Qualification: Patients with a history of TBI who report visual symptoms like blurred vision, double vision, eye strain, headaches with reading, or difficulty with visual tracking. 2. Initial Assessment: Screen for oculomotor deficits using tests like the Vestibular/Ocular Motor Screening (VOMS). Assess saccades, smooth pursuits, convergence, and VOR. Refer to a neuro-optometrist for a comprehensive vision exam. 3. Treatment Protocol: Start with basic exercises and progress as the patient improves. For example: Pencil Push-ups (3 sets of 10 reps, 2x/day), Brock String (3 sets of 5 reps, focusing on each bead for 10 seconds, 2x/day), and Saccadic Eye Movements between two targets (1 minute, 3 sets, 2x/day). 4. Progression Criteria: Progress the exercises by increasing the speed, duration, or complexity. For example, add head movements during saccades or use a more complex background. 5. Red Flags: Watch for increased headaches, dizziness, or nausea during or after exercises. If these symptoms persist, reduce the intensity of the exercises or refer back to the neuro-optometrist.

Common Mistakes to Avoid

•Prescribing generic eye exercises without a proper assessment.
•Not collaborating with a neuro-optometrist.
•Failing to educate the patient about the process and potential for slow progress.
•Neglecting to integrate vision therapy with other aspects of TBI rehabilitation.

Frequently Asked Questions

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