Treatment for headaches and dizziness caused by traumatic brain injury appears promising, study says

June 04, 2010

ANN ARBOR, Mich. - A recent retrospective study by four Michigan physicians shows strong evidence that symptoms of headache, dizziness and anxiety in some patients with traumatic brain injury potentially could be alleviated or even eliminated with specialized eyeglass lenses containing prisms.

The paper was published in the April 2010 issue of Physical Medicine and Rehabilitation. The investigators included doctors from three southeast Michigan hospitals and one in private practice, and involved 43 patients with TBI.

"This represents a new approach to the treatment of post-concussive symptoms," says Mark S. Rosner, M.D., adjunct clinical instructor in the Department of Emergency Medicine at the University of Michigan Medical School and Emergency Department staff physician at St. Joseph Mercy Hospital in Ann Arbor. "Vision was known to be affected by TBI, but now it appears that the vision abnormalities caused by the TBI are causing the other post-concussive symptoms."

The study suggests that TBI appears to be causing visual image misalignment - or vertical heterophoria. To correct this misalignment and prevent double vision, the eye muscles are utilized to force the eyes back into proper alignment. This causes the eye muscles to become overworked, strained and fatigued, which accounts for many post-concussive symptoms, including headaches, dizziness, anxiety and neck pain. The use of prismatic eyeglass lenses to realign the images and reduce or eliminate eye muscle overwork led to a 71.8 percent reduction of patient's symptoms.

TBI affects 15 to 20 percent of our servicemen and women returning from Iraq and Afghanistan - caused mostly by explosions - and approximately 2 million people per year in the U.S. - caused mostly by falls, auto accidents and sports injuries. Approximately 10 to 25 percent of patients with TBI still have significant post-concussive symptoms one year after their injury.

"Treatment involves a multifaceted approach, including physical therapy, occupational therapy and multiple medications, and can take years to complete," says Jennifer E. Doble, M.D., a physiatrist at St. Joseph Mercy Hospital, Ann Arbor. "Prismatic lens treatment seems to allow the other therapies to be effective more quickly. And as a result, patients get better quicker, reducing the time and cost of caring for this patient population."

The first patient with TBI was recognized as having vertical heterophoria in 2005 by two of the study co-authors - Doble, a TBI rehabilitation specialist - and Debby L. Feinberg, O.D., an optometrist at Vision Specialists of Birmingham, Birmingham, Mich. The overlap of TBI and vertical heterophoria symptoms was significant: headaches, neck ache, upper back pain, dizziness, nausea, anxiety and reading difficulties. To date, no single unifying cause of TBI symptoms had been identified.

Doble initially saw patients with TBI. When vertical heterophoria was suspected, they were then referred to Feinberg for further evaluation.

"A retrospective analysis of the data from these patients was performed, and 43 patients were diagnosed with vertical heterophoria and included in the study," says Feinberg. "These patients had persistent post-concussive symptoms despite receiving standard treatments and medications for an average of 3.5 years."

A diagnostic and therapeutic process developed by Feinberg was used to identify and treat vertical heterophoria. Prism lenses were added to the patient's baseline prescription, which resulted in a 71.8 percent reduction of symptoms in an average of 3.5 months.

"Our study concluded that in this group of patients who developed post-concussive symptoms and vertical heterophoria symptoms because of their TBI, malfunctioning of the binocular visual system was found to be a single common factor shared by all patients," says Arthur J. Rosner, M.D., an otolaryngologist at the Department of Otolaryngology, William Beaumont Hospital, Troy, Mich.

"Treatment of the vertical heterophoria with prismatic eyeglass lenses was found to be effective in reducing symptoms associated with both TBI and vertical heterophoria."
The physicians who contributed to this study were Mark Rosner, Doble, Feinberg and Arthur Rosner.

PM&R paper:

Funding source: self-funded.

Patents/conflicts: none

Journal reference: Physical Medicine and Rehabilitation, 10.1016/j.pmrj.2010.01.011

The St. Joseph Mercy Health System, Ann Arbor, Mich., has also distributed this press release.

About Vertical Heterophoria

Vertical heterophoria is a binocular vision condition that causes symptoms (headaches, dizziness, anxiety, nausea, neck pain and reading difficulties) that are common to many other medical conditions.

It was first identified in the 1880s by ophthalmologist George T. Stevens, M.D. An optometrist, Raymond Roy, O.D, did further work on this condition in the 1950s and 1960s. However, the condition remains relatively unknown today because difficulties in measuring the amount of prism needed to correct the vertical misalignment hindered work in this field.

Feinberg and Arthur Rosner recognized this condition in 1995 in patients who were suffering from dizziness unrelated to TBI. Treatment of over 4000 vertical heterophoria patients and 750 patients with TBI and VH since then by Feinberg has led to the advances in the diagnosis and treatment that has propelled this research forward.

More information about VH is available at or by contacting Feinberg's office at 248-258-9000.

The origins of this VH research

Arthur Rosner had symptoms of vertical heterophoria as a young man and was treated in 1985 by Feinberg. (She later became his sister-in-law.) As an ENT physician, Rosner saw patients with complaints of headaches, dizziness, anxiety, neck pain and difficulty with balance and coordination whose symptoms were not caused by inner ear/vestibular system abnormalities.

He began to notice a pattern that seemed to have a visual cause, so he started to refer these patients to their eye doctors. But they all returned to him, telling him that nothing wrong was found. In 1995 he began referring them to Feinberg, who was able to help them. Together, they began developing a questionnaire to aid in the diagnosis of this condition, and Feinberg refined her diagnostic and therapeutic techniques.

Doble became aware of vertical heterophoria in 2005 when one of her TBI patients improved significantly after being treated by Feinberg. After meeting with Feinberg to learn more about VH, she recognized that many of her patients had VH symptoms that could be treated with prismatic lenses.

Mark Rosner (who is the brother of Arthur Rosner and married to Feinberg) became involved in 2007. He is the principle investigator and lead writer for the study, and he has taken the lead in elucidating the visual optics and physiology/pathophysiology of vertical heterophoria, resulting in the discovery of a new ocular posture (vertical transphoria) and a new ocular movement (compensatory vertical divergence).

University of Michigan Health System

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