Neurovisual rehabilitation: recent developments and future directions.

Central visual and oculomotor disorders are present in some 20%-40% of patients in neurological rehabilitation centres. Gianutsos reported that 50% of the patients in a head trauma rehabilitation centre show visual system disorders not assessed before although most of the patients were chronic and had been treated in other hospitals previously. In a large sample of 314 patients with postchiasmatic visual field disorders from a rehabilitation department 70% had a parafoveal visual field sparing of 5° or less. Of these patients, 50%-70% subjectively reported and objectively showed chronic reading and visual exploration deficits. Furthermore, visual field disorders are associated with an adverse prognosis in outcome studies according to life table analysis and impair the success of vocational rehabilitation. 7 Spatial-perceptual deficits may delay the rehabilitation progress in physiotherapy, 9 lead to complications due to repeated accidents, and correlate highly with deficits in activities of daily living (dressing, transfers, or manoeuvring a wheelchair. In the presence of limited financial resources in health policy it might be argued that central visual disorders do not require treatment as they do not aVect outcome adversely. Although nothing supports this opinion there is some evidence to the contrary. Cutting inpatient stroke rehabilitation to a maximum of 60 days (in Italy) led to a deterioration in neuropsychological and activities of daily living in patients with stroke, especially those with right hemispheric lesions. Hence, withdrawing neuropsychological treatment deteriorates functional performance and creates new costs. Whereas the systematic treatment of language, speech, and motor disorders is traditionally viewed as unequivocally necessary the possible influence of visual-sensory and oculomotor disorders on the patient’s outcome is still neglected in neurorehabilitation. This review summarises therapeutic approaches for acquired central visual disorders. It is split into five parts. After an introduction into the role of vision in neurorehabilitation, the second part deals with current theorising of recovery from brain damage, cortical plasticity, and implications for rehabilitation. Part three summarises low level and high level visual disorders after brain lesions and their resulting impairments. In part four therapeutic approaches for these disorders are detailed, where available. In the last part, future perspectives for neurovisual rehabilitation including new experimental, but unexplored approaches are outlined. Pharmacological stimulation eVorts and disorders of the anterior visual pathways are not covered. Visual neglect is only alluded to in the section of future directions, to indicate new promising treatment techniques that might be relevant for other visual disorders as well (see Robertson for a recent, excellent review on neglect rehabilitation).