Visual & Vestibular Consequences of Acquired Brain Injury. I. B. Suchoff, Kenneth J. Ciuffreda, and Neera Kapoor, eds. Santa Ana, CA: Optometric Extension Program, 2001. 244 pages, softcover.

Disturbances of the visual and vestibular systems are familiar problems to rehabilitation professionals treating people with acquired brain injuries. Many rehabilitation physicians are accustomed to the traditional medical assessment of visual and vestibular complaints, or rely upon the assistance of ophthalmologists or otolaryngologists. However, the typical medical exam delivered at the bedside or in the office is insufficiently sensitive to detect the etiology of many visual or vestibular system problems. As a result, "subtle" but correctable difficulties may be underdiagnosed and undertreated. The use of vision exercises and other optometric techniques remains somewhat controversial in the more traditional medical model and has been criticized as lacking evidence-based support. Therefore, many patients have not been afforded the opportunity of at least a trial of these interventions that may facilitate their functional recovery, even if the data are lacking on large series of subjects with acquired brain injury. Certainly rehabilitation physicians use medications and other tools to facilitate functional recovery that have little more evidence to support their use (although they may be considered standard practice) but have greater risks of iatrogenic complications or side effects.

If the intent of the authors was to increase awareness of what optometry could offer our patients with brain injuries, then, to some extent, they were successful. I have already begun investigating those optometrists in my corner of mid-America who have the interest and skill set to provide the assessment and interventions described in this text.

In spite of this behavioral change, this book cannot be recommended to the majority of rehabilitation professionals. The target audience for this book was clearly optometrists and not therapists, psychologists, or physicians in rehabilitation. The material represents a series of papers from a course at a national meeting of optometrists in 1999 that have been edited and expanded. This is not to say that the text was poorly written. The majority of the chapters are quite readable, when not encumbered by optometric terminology. This is particularly true of those by the editors themselves, as well as those by Hibbard, Gianutsos, Jackowski, and Malamut. For the most part, the chapters follow a logical sequence. The actual editing of the book could have been more robust, however; there was a great deal of redundancy, particularly in recurrent discussions of pathophysiology and epidemiology of brain injury.

The reasons this book cannot be recommended to the majority of rehabilitation professionals are that the chapters related to rehabilitation per se are very superficial and lack much in the way of literature support or critical analysis of the literature, although there is a great deal of relatively valid opinion. The discussion by Malamut on vestibular therapy and ocular dysfunction and the chapter by Giannutsos and Suchoff on an expanded visual field assessment for brain injured patients are notable exceptions, with good references. Similarly, the discussions of pathophysiology are very limited and not illustrative for the most part of the relationship to the optometric problems discussed. Because the target audience is optometrists, it is not surprising that there is little text devoted to defining or explaining optometric terminology or techniques. This is quite frustrating for the rehabilitation professional interested in incorporating optometry into a rehabilitation program. Certain chapters may be useful to educators and students in rehabilitation especially that on the neuropsychological evaluation by Hibbard and colleagues. It provides a good overview of what domains are tested (though it doesn't discuss specific tests) and provides some useful tips on accommodations that should be employed by optometrists and other clinicians in working with people with brain injuries to compensate for the common cognitive and neurobehavioral deficits. The chapter on the integration of visual and vestibular systems in balance disorders by Rosen and colleagues is also well-written and could be useful to students in rehabilitation studying vestibular therapies.

In spite of the difficulties in trying to interpret optometric linguistics, certain authors were able to provide some interesting points related to their topic. The chapter on factors affecting prognosis with regard to vision therapy by Scheiman and Gallaway helps to explain why some people respond to intervention and some do not. The discussion of "egocentric" localization by Kapoor and colleagues provided the reader with a fresh, alternative perspective on the visual and spatial integration problems associated with nondominant posterior parietal dysfunction. Jackowski provides a cogent argument, based both on his own studies and on a thorough literature review, to support the organic nature of light sensitivity complaints in people with brain injury. He further discusses a coincident problem that may not be self-identified by the patient: difficulty with dark adaptation. He postulates that the problem is postgeniculate, but unfortunately does not provide much in the way of imaging studies to help support this contention; functional imaging as a component of this research would certainly have been interesting.

There is very little specific discussion of training techniques, however, and although some chapters do provide case reports or actual studies, the majority involves only a small number of subjects. The data presented in the book as whole do not approach a very rigorous level of evidence based medical practice, and there is no specific discussion of the controversy regarding the effectiveness of the techniques mentioned.

Although this book did ultimately titillate the reader's interest in visual rehabilitation, it cannot be recommended to the average rehabilitation professional because the most interesting and potentially useful practice-changing material is very difficult to fathom and use. Similarly, the known controversies regarding the effectiveness of some of these techniques are not directly discussed or refuted. This subject is very important and interesting, and the editors as well as the majority of other authors appear to be both experienced and knowledgeable in their topic areas. One would hope they would develop a textbook that targets rehabilitation professionals and introduces their profession and potential contributions to the rehabilitation of people with brain injuries to us in a more useable, scientifically rigorous, and comprehensible way. Such a text by these editors could receive a considerably stronger recommendation for inclusion in a rehabilitation professional's library.