CARROLL UNIVERSITY

Doctor of Physical Therapy Program

Critically Appraised Topic

THE USE OF VERSION, VERGENCE AND ACCOMMODATION THERAPY FOR TREATING CONVERGENCE DYSFUNCTION

Clinical Scenario:
What is best practice for treating patients with oculomotor dysfunction following concussion or mild TBI? Include recommendations for screen
time following concussion, as well as the factors that contribute to or slow recovery (i.e., prognostic factors).

Clinical Question:
This CAT will focus on the use of vergence, version and accommodation therapy for effectively treating convergence dysfunction in
individuals with a mild traumatic brain injury.

Clinical Bottom Line:

There is evidence that vergence, version and accommodation therapy are effective for treating convergence dysfunction in
individuals with a mTBI. More high-quality research needs to be performed to be more confident in the efficacy of this treatment.
Due to the lack of evidence on this protocol, this is the best available evidence.

Refresh Date: 3/2020

Author(s): Tacy Camenga Date Created: 3/1/2018

Key Findings
 Key findings
o Rehabilitation interventions for vergence, version and accommodation are shown to improve reading rate, VSAT (Visual Search
Attention Test) percentile, fixation and VEP (Visual Evoked Potential) amplitude.
o Sham training is not effective and results in little to no improvement in symptoms.
 Breadth of literature related the topic
o Not a lot of research on the use of PT interventions but there is a lot of research relating to optometrist implemented interventions.
 Research attributes
o Clinical trials, case series and case reports are most common.
o Used standardized tests and instrumentation
o Was blinded when possible
o Interventions were not repeated to check reliability of intervention
o Not randomized
o Low sample sizes/research quality
o Low training hours
o No long-term follow-up
o Similar age ranges
o Most research was taken from the same areas
o May not have control groups
 Take home or important finding reviewed
o The combination of COR with other treatments improved reading rate and fixation measurements.
 Clinical relevance
o While these specific interventions are not used in the physical therapy setting, if an individual has chronic convergence insufficiency,
these treatments may be important in their recovery.

Author(s): Tacy Camenga Date Created: 3/1/2018

Search Methodology:
Search Resources Search Terms Limits # of Articles
PubMed Oculomotor dysfunction AND None 10
1
treatment AND TBI
PubMed Oculomotor rehabilitation AND None 4
2 vergence AND Mild Traumatic Brain
Injury
CINHAL Oculomotor dysfunction AND reading None 2
3
AND mTBI
4. CINHAL Convergence insufficiency AND mTBI None 2

Search Results Summary:

Results
Case report (2), Review (1), Case
Series (1), Clinical trial (2),
1
Retrospective (2), Systematic review
(1), Cohort Study (1)
Review (1), Case series (1), Clinical trial
(2)
2
3 Case Series (1), Cohort study (1)
Case report (1), Retrospective (1)
4 oculomotor dysfunction and
Reasons for Inclusion
- Applicable to mTBI,
oculomotor dysfunction and
treatment
- Applicable to mTBI,
treatment
Reasons for Exclusion # of Articles
Included
- Not specific to mTBI 1
- No full text available
- Not specific to treatment
- Does not include oculomotor
component
- Did not treat vergence,
accommodation and version
- Not applicable for treatment
- Not related to treatment 1
- Not related to COR

Research Participant and Study Characteristics:

Reference Participant Key Clinical Control Intervention Experimental Intervention Level of
Characteristics (frequency/duration) (frequency/duration) Evidence
Thiagarajan et al. - 12 subjects Cross-over- each subject is their 6 wks oculomotor training (OMT) 4
2014 - Ages: 23-33 yes own control
Author(s): Tacy Camenga Date Created: 3/1/2018
 - Mean age: 29±3 6 weeks sham training (ST)
- Documented mTBI at
least in the past year
- At least one sign and
symptom of non-
strabismic oculomotor
dysfunction
- Stable systemic and
cognitive health
- Selected from the
Raymond J. Greenwald
Vision Rehabilitation
Center at the State
University of New York,
State College of
Optometry, University
Optometric Center, New
York City
Yadav et al. 2014 - 7 participants
- Age range: 25-38
- Age mean: 29.5
- mTBI in the past 6 years
- Selected from the
Raymond J. Greenwald
Vision Rehabilitation
Center at the State
University of New York,
Author(s): Tacy Camenga
- 2- 60 min training
sessions/wk, 45 mins
actual training with the
rest as rest periods
- Total training time of 9
hours
- SHAM Version- bifixated
estimated center of a
computer screen,
simulated reading
training
- SHAM Vergence- targets
were pictures, letters and
numbers on a computer
screen
- Sham Accommodation-
alternation of lens
flippers both monocularly
and binocularly
- No control group
Date Created: 3/1/2018
- 2- 60 min training
sessions/wk, 45 mins actual
training with the rest as
rest periods
- Total training time of 9
hours
- 15 mins each of version,
vergence and
accommodation training
- Version: COR
(Computerized Oculomotor
Rehabilitation) program
using the rapid-serial visual
presentation paradigm
with binocular viewing
- Horizontal vergence: slow
ramp vergence and rapid
step vergence with both
amplitude and facility were
trained
- Accommodation: Step
accommodative amplitude
and binocular step
accommodative facility
- Oculomotor Vision 4
Rehabilitation (OVR):
training of version,
vergence and
accommodation
- Performed 2x/week for 6
weeks
 State College of
Optometry, University
Optometric Center, New
York City

Outcomes:
Reference Event/Outcome Mean (SD) ES &/or NNT
Control Group Experimental Group

Thiagarajan et al. Reading rate No change Baseline: 142 (10) -0.82

2014 Post-OMT: 177 (14)
Fixation No change Baseline: 164 (10) 0.81
Post-OMT: 135 (11)
Regression No change Baseline: 30 (3) 0.7
Post-OMT: 23 (4)

Outcomes:
Reference Event/Outcome Experimental Group ES &/or NNT

Yadav et al. 2014 VEP amplitude Before OVR: 17.10 (SEM ± 3.85) Standard deviation not provided
After OVR: 19.15 (SEM ±3.8)
VEP latency Before OVR: 105 (SEM ±2.31 Standard deviation not provided
After OVR: 105 (SEM ±1.98)
VSAT Percentile Before OVR: 40.25 (SEM ±12.31) Standard deviation not provided
After OVR: 59.5 (SEM ±9.25)

Author(s): Tacy Camenga Date Created: 3/1/2018

References:
Thiagarajan P, Ciuffreda K, Capo-Aponte J, Ludlam D, Kapoor N. Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI):
An integrative approach. Neurorehabilitation [serial online]. January 2014;34(1):129-146. Available from: CINAHL Plus with Full Text, Ipswich,
MA. Accessed March 1, 2018.

Yadav N, Thiagarajan P, Ciuffreda K. Effect of oculomotor vision rehabilitation on the visual-evoked potential and visual attention in mild
traumatic brain injury. Brain Injury [serial online]. June 2014;28(7):922-929. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed
March 2, 2018.

Author(s): Tacy Camenga Date Created: 3/1/2018