Dynavision D2 for Rehab

COMMON APPLICATIONS
AND PATIENT INDICATIONS
FOR THE DYNAVISION D2™
IN CLINICAL REHABILITATION
Phil Jones
Founder and President
Jennifer Fortuna, MS, OTR/L
Business Training Coordinator
© 2015 Dynavision International, LLC

OVERVIEW
INTRODUCTION
 Theoretical Principles
 Operating System
 Programmable Options
 Data Management
PRACTICAL
ASSESSMENT AND TRAINING
 Clinical Applications
 Modifications
PRACTICAL
TEAM ACTIVITY

INTRODUCTION
Theoretical Principles
Operating System
Programmable Options
Report Management

INTRODUCTION
Originally developed for sports vision training of athletes, the
Dynavision D2™ has proven effective for use in visual, cognitive
and physical rehabilitation; driver retraining; concussion baseline
testing; and concussion management (Anderson et al., 2011;
Klavora, Heslegrave, & Young, 2000; Wells et al., 2014; Klavora, &
Leung, 1996; Clark et al., 2014).

THEORETICAL PRINCIPLES
Dynamic Interactional Approach (Toglia, 2005)
Focus: Restore functional performance for clients with cognitive
dysfunction due to brain injury or developmental disability.
Applications: Metacognition, executive function, problem
solving, attention, visual processing, motor planning, and effort.
Treatment: Self-awareness develops within the context of
engagement, cues and strategies applied by therapist.
Transfer of Learning: Skills improve through practice on a
cognitive continuum.

Person-Environment-Occupation-Performance (PEOP)
(Christiansen & Baum, 2005; Law et al., 1996)
Focus: Occupations (valued roles, tasks, activities) and
functional performance as selected by the client.
Applications: Intrinsic physiological, psychological, cognitive,
neurobehavioral and spiritual factors impacting performance.
Treatment: Adapt the task to match the client’s abilities (intrinsic
factors). Facilitate client’s ability to control movement, modulate
sensory input, integrate sensory information, compensate for
sensory deficits, and modify neural structures.
Transfer of Learning: A sense of accomplishment will create a
reinforcing positive cycle of intrinsic and extrinsic reward.

Neurodevelopmental Treatment (NDT) (Bobath, 1950)
Goal: Client-centered, hands-on, problems solving approach
used to manage and treat clients with CNS pathophysiology.
Applications: Balance, postural control, movement, mobility,
proprioception/vestibular, weight bearing, vision and
developmental disability.
Treatment: Therapist uses his or her own body to promote
efficient movement and avoid unwanted motor responses
Transfer of Learning: Underlying deficits gradually improve
over time as a result of skilled handling and neuroplasticity.

Warren’s Theory of Visual Development (Warren, 1993)
Focus: A hierarchy of visual processes used to identify the cause
of underlying visual deficits.
Performance: All levels must work together. Foundational
weakness affects function at all levels.
Transfer of Learning: Oculomotor control, central/peripheral
visual fields and visual acuity lay the foundation for higher visual
skills.

OPERATING SYSTEM
Adjustable light board (4’ x 4’ )
Wall or stand mount installation
Netbook interface
Auditory feedback
Game-like presentation
Printer (optional)

PROGRAMMABLE OPTIONS
 Light board with 64 LED Buttons
 Five concentric rings
 Four quadrants
 Modes (A,B,C, Reaction Test)
 Green Lights (percentage/area)
 Tachistoscope (T-Scope)
 Run time
 Light speed

Rings
 Activate or deactivate the light board by individual rings

Quadrants
Activate or deactivate the light board by quadrant

 Run Time
 T-Scope
 Make Repeatable
 Quadrants
 Rings
Proactive (Mode A)
A light will illuminate and the patient must touch the button to
deactivate it. When one light is deactivated, another will appear
at a random location. This cycle continues until the run is over.

 Run Time
 Lights (speed, color, area)
 T-Scope
 Make Repeatable
 Quadrants
 Rings
Reactive (Mode B)
A light will illuminate for a preset length of time. The patient must
deactivate the light before it moves to a new random location.
This cycle continues until the run is over.

 Run time
 Light speed
Scan (Mode C)
Position the patient 6 feet from the D2™. A light will travel around
the periphery of the 6th ring at a preset speed, changing directions
every 15 seconds. The patient will track the light without moving
his/her head until the run is over.

Reaction Time Test (Mode D):
The patient will hold down an illuminated button, until another
button appears at a random location, then release the first button
to strike the second button as quickly as possible. This mode
consists of six tests, three for each hand.
 Establish a visual motor baseline.
 Monitor progress over time.

Green Lights
• Select the percentage and area of green lights

Tachistocope (T-Scope) Basic and Advanced Options
 Divide visual attention between the light board (peripheral
vision) and the LED screen (central vision).

Run Time
 Select length of run time

Light Speed
 Select speed of flashing lights

REPORT MANAGEMENT
Performance data is quantitative and objective to ensure accurate
reporting for initial baseline evaluation and progress monitoring.

REPORT MANAGEMENT
Formats:
1. Score
2. Reaction Time
3. Results by Quadrant
4. Text report
5. Time/score breakdown
 Easy to read
 Printable
 Objective
 Stored in patient history

REPORT MANAGEMENT
Results by Quadrant:
 Total score and average reaction time
 Divided by quadrant and color
 Separates red/green light scores and average reaction times

REPORT MANAGEMENT
Text Report:
 Total Score and average reaction time
 Displays fastest/slowest reaction time
 Statistics on quadrants, rings, hits, and average reaction time

REPORT MANAGEMENT
Time/Score Breakdown:
 Total score and average reaction time
 Provides hits/lights by interval
 Displays location of hits on light board

REPORT MANAGEMENT
Red Light Score:
 Red Light Score
 Red Score Lights
 Red Average Reaction Time

REPORT MANAGEMENT
Normative Data

PRACTICAL
From Theory to Practice
Programmable Options
Report Management

FROM THEORY TO PRACTICE
NDT Principles and the Dynavision D2™
Patient:
A 67-year-old female,12 weeks post right hemispheric
cerebrovascular accident (CVA). Residual effects include left side
hemiparesis, left visual unilateral inattention, flexor tone in the left
upper extremity and poor standing balance.
Treatment:
Use the D2™ as a preparatory intervention to improve upper
extremity range of motion, standing activity tolerance, bilateral
coordination and visual awareness of the neglected side.

Objectives:
• Use therapeutic handling to increase access, promote efficient
movement and block unwanted motor responses.
• Combine weight-bearing with reach outside base of support to
encourage active extension of the upper extremity for balance.
• Address visual deficits through use of auditory and tactile input
to retrain vision through association.
• Incorporate clinical observations and objective data into notes.

 The client is seated within arm’s length of the light board.
 Therapist is seated on the client’s affected side.
 Therapist blocks clients affected leg at the knee and shin.

 Therapist facilitates safe sit to stand.
 Therapist provides support at the trunk and clavicle.

 Therapist stabilizes affected arm in weight bearing.
 The client reaches and strikes targets with unaffected arm.
 Therapist supports weight shifts to/from affected side.

Programming:
Mode: Proactive (Mode A)
T-Scope: Off
Quadrants: All
Rings: 1-3 activated
Run Time: 30 seconds
Suggested Instructions:
“When a flashing red light appears, hit it as fast as you can.
Keep hitting the red lights until the run is over.”f

DATA MANAGEMENT
Clinical Observations
 Unsteady balance (seated and/or standing)
 Pauses before striking buttons
 Level of physical assistance to complete task
 Eye-hand coordination
Objective Data
• Score
• Average reaction time
• Significant differences in score/reaction time demonstrating
visual neglect/awareness of affected side
• Standing/seated activity tolerance

Dynamic Interactional Approach
Saccadic training is usually the first step in helping a patient with
hemianopsia compensate for visual field loss.
With lights dimmed, the patient should be able to locate the
glow of the red light to direct compensatory head movements.
In the beginning, encourage wide head movements. As the
patient becomes comfortable with the task gradually reduce the
head movement to encourage a wider saccade.

Tips to Increase Client Insight:
 Provide auditory cues (finger snapping) to remind client to look
at the affected visual field.
 Share clinical observations with the client. “When you did this, I
noticed this happened.”
 Identify the client’s own compensatory strategies. Provide
opportunities use these strategies whenever possible.
 Use verbal cues to increase insight.
 “Pay extra attention to the affected side,”
 “Where will I ask you to look?”
 “What part of this task did you find difficult?”

Dynamic Interactional Approach and the Dynavision D2™
Objectives:
 Initiate wide head turns towards the affected visual field.
 Increase speed and accuracy of eye movements.
 Improve visual attention to detail.
 Quickly shift attention between the central visual field and
peripheral visual field.
 Incorporate body movements to improve vision and perception.
 Increase insight into how the visual impairment impacts function.

Dynamic Interactional Approach and the Dynavision D2™
Programming:
Mode: Proactive (Mode A)
T-Scope: Off
Quadrants: Upper/lower left
Rings: All
Run Time: 60 seconds
Suggested Instructions:
“Turn your head towards the left side of the light board. When you
see a red light flash, hit it as fast as you can. Keep hitting the red
lights until the run is over.”f

DATA MANAGEMENT
Clinical Observations
 Ability to initiate wide head turns toward affected side
 Client’s ability to shift attention between visual fields
 Unsteady balance (seated and/or standing)
 Client’s level of insight into impairments
Objective Data
• Score
• Average reaction time
• Significant differences in score/reaction time between quadrants
• Standing/seated activity tolerance

ASSESSMENT & TRAINING
Clinical Applications
Modifications

CLINICAL APPLICATIONS
The programmable options standard with Dynavision D2™
software enable the clinician to facilitate individualized treatment
programs for clients of different ages, abilities, and conditions.

The Dynavision D2™ has been recognized as the premier
visual-motor reaction training system for over 25 years. Currently
the D2™ utilized by a variety of medical professions.
 Physical Therapy
 Occupational Therapy
 Speech Therapy
 Optometry
 Neurology

Visual Rehabilitation
 Visual reaction time
 Visual-motor integration
 Visual-perceptual processing
 Visual-spatial integration
 Visual processing speed
 Visual attention
 Visual memory
 Binocular vision
 Integrate central/peripheral vision
 Compensatory training strategy for visual field deficits

Cognitive Rehabilitation
 Attention regulation
 Problem solving
 Impulse control
 Insight into disability
 Vestibular function
 Executive function
 Sustained and divided attention
 Metacognitive strategy training
 Sequential and working memory
 Increase patient insight into underlying deficits

Physical Rehabilitation
 Bilateral coordination
 Eye-hand coordination
 Manual dexterity
 Standing activity tolerance
 Physical strength and endurance
 Static and dynamic balance
 Postural control
 Seated and standing balance
 Functional mobility
 Upper extremity range of motion
 Reach outside base of support

MODIFICATIONS
Adjust for the patient’s strengths/needs:
 Remove visual/auditory distractions
 Dim lights to increase contrast
 Adjust positioning/posture
 Consider “add-on’s”

MODIFICATIONS
Positioning:
 Seated vs. standing
 Sturdy chair (stand and reach)
 Bar stool
 Static vs. dynamic
 Exercise ball
 Bosu ball
 T-Stool
 Balance board
 Foam cushion
 Incline/wedge

MODIFICATIONS
• Red/Green Glasses (Bernell.com)
• Assess binocular vision
• 50% green lights
• Rear View Mirror
• Divided attention
• Driver rehabilitation
• Head Lamp
• Improve eye-hand coordination
• Dissociate eye-head movement

MODIFICATIONS
• Red and Green Gloves
• Provide visual cues
• Match to red/green buttons
• Assist with crossing midline
• Picture Cards
• Sequential memory
• Divided attention
• Multi-tasking

PRACTICAL
Concussion Baseline Test and Exam
Key Points

CONCUSSION BASELINE TEST
1. Proactive (Mode A)
2. Reaction Test (Mode D)
Programs come standard with D2™ software.

Proactive (Mode A)
Step 1: Click *Proactive, 1 min
Step 2: Click Run Program

CONCUSSION EXAM
Verbal Instructions:
“Hit the red buttons as quickly as you can until time runs out.”
Clinical Observations:
 Left/right symmetry of the upper extremities
 Unsteady balance
 Alternating hands instead of using hand that is closest
 Pauses before striking or calling/adding numbers

CONCUSSION EXAM
Data Management:
Note the client’s average reaction time and clinical observations.

Reaction Test (Mode D):
Step 1: Click *Reaction Test
Step 2: Click Run Program

CONCUSSION EXAM
The Reaction Test consists of 6 tests:
 3 for the right hand
 3 for the left hand
“Press and hold the red button. When a second red light
appears strike it as quickly as you can.”

Test 1: Right Hand – 4 Choice

Test 2: Left Hand – 4 Choice

Data Management:
A text report will appear at the conclusion of the sixth and final
reaction test. Visual, Motor, and Physical reaction times, number
of attempts and number of false starts are indicated.

To Calculate Score:
1. Add the total number of hits and the T-Scope score.
2. Subtract the number of errors.
3. Multiply this number by two to determine the final score.
Example:
Number of hits 38
T-Scope Score +8
Errors -2
Final Score = 44
44 X 2 = 88
Baseline Score = 88

Score Interpretation:
 A less than 10% reduction in baseline score at retest
indicates a passing score.
 A 10% reduction in baseline score at retest indicates a
failing score.

CONCUSSION EXAM
1. Memory Test 1
2. Memory Test 2
3. Memory Test 3
Programs are created by the clinician and saved in program history.

CONCUSSION EXAM
Memory Test 1:
Step 1: Click Add Program
Step 2: Select Reactive Mode
Step 3: Activate rings 1, 2, and 3

Memory Test 1:
Step 4: Under T-Scope Option, click Change.
Step 5: Set flash at 1 digits for 1.00 seconds. Click OK.

CLINICALAPPLICATIONS
Memory Test 1:
Step 6: Click Save Program.
Step 7: Name the program Memory Test 1. Click OK.
Step 8: Click Run Program.

CONCUSSION EXAM
Memory Test 1:
“Single digit numbers will flash on the screen. Hit the red buttons
as quickly as you can. At the same time, call the numbers out.”
Data Management:
Note the client’s score, ability to call numbers accurately.

CONCUSSION EXAM
Memory Test 2:

CONCUSSION EXAM
Memory Test 2:
Step 7: Name the program Memory Test 2. Click OK.

CONCUSSION EXAM
Memory Test 2:
“Numbers will flash on the screen. Hit the red buttons as quickly as
you can. Call out the first number, remember the second number,
and then call out the sum. For example, if the first number is 4 and
the second number is 3, you would say 4 followed by 7.”
Data Management:
Note client score, ability to call and add numbers accurately.

CONCUSSION EXAM
Memory Test 3:

CONCUSSION EXAM
Memory Test 3:
Step 5: Under Lights/No Green Lights, click Change.
Select 20%.

CONCUSSION EXAM
Memory Test 3:
Name the program Memory Test 3. Click OK.

CONCUSSION EXAM
Memory Test 3:
“Numbers will flash on the screen. Hit the red buttons as quickly as
you can. Call out the first number, remember the second number, and
then call out the sum. When you see a green light, call green. Do not
hit green.”
Data Management:
Note client score, ability to call and add numbers, ability to call green.

KEY POINTS
 The Dynavision D2™ increases insight into underlying deficits
and supports generalization of new skills into everyday life.
 Programmable options facilitate “just-right” challenges
appropriate for clients of various ages, stages, and conditions.
The applications are endless!
 D2™ software produces objective performance data to establish
accurate baseline measurements and monitor progress.
 The D2™ is fun! Tapping into the patient’s intrinsic motivation
makes participation rewarding in-and-of itself.

REFERENCES
Anderson, L., Cross, A., Wynthein, D., Schmidt, L., & Grutz, K. (2011). Effects
of Dynavision training as a preparatory intervention post cerebrovascular
accident: a case report. (2011). Occupational Therapy in Health Care, 25(4),
270-282.
Bobath, B. (1990). Adult hemiplegia: Evaluation and treatment (3rd ed.).
London, UK: Heinemann.
Christiansen, C., & Baum, C. M. (2005). Occupational therapy: Enabling
function and well-being (3rd ed.). Thorofare, NJ: SLACK Incorporated.
Clark, J.F., Graman, P., Ellis, J.K., Mangine, R.E., Rauch, J.T., Bixenmann, B.,
Hasselfeld, K.A., Divine, J.G., Colosimo, A.J., & Myer, G.D. (2014). An
Exploratory study of the potential side effects of vision training on concussion
incidence in football. In press.
Cozolino, L. & Sprokay, S. (2006). Neuroscience and adult learning. New
Directions for Adult Learning and Continuing Education, 110, 11-19.

REFERENCES
Klavora, P., Heslegrave, R.J., & Young, M. (2000). Driving skills in elderly
persons with stroke: comparison of two new assessment options. Archives of
Physical Medicine and Rehabilitation, 81, 701-705.
Klavora, P., & Leung, M. (1996). Case study I. In P. Klavora & M. Warren
(Eds.), Dynavision for rehabilitation of visual and motor deficits: A user’s
guide. Lenexa, KS: visAbilities Rehab Services, Inc.
Law, M., Cooper, B., Strong, S., Steward, D., Rigby, R., & Letts, L. (1996). The
person-environment-occupation model: A trans-active approach to occupational
performance. Canadian Journal of Occupational Therapy, 63, 9-23.
Toglia, J. (2003). Multicontext treatment approach. In E. Creapeau, E. Cohn, &
B. Boyt Schell (Eds.), Willard and Spackman’s occupational therapy.
Philadelphia, PA: Lippincott, Williams & Wilkins.
Toglia, J. & Abreau, B. (1987). Cognitive rehabilitation. New York, NY: Authors.

REFERENCES
Warren, M. (1990). Identification of visual scanning deficits in adults after CVA.
American Journal of Occupational Therapy, 44, 391-399.
Warren, M. (1993). A hierarchical model for evaluation and treatment of visual
perceptual dysfunction in adult acquired brain injury. I. American Journal of
Occupational Therapy, 47, 42-54.
Warren, M. (1993). A hierarchical model for evaluation and treatment of visual
perceptual dysfunction in adult acquired brain injury. II. American Journal of
Occupational Therapy, 47, 55-66.
Wells, A.J., Hoffman, J.R., Beyer, K.S., Jajtner, A.R., Gonzalez, A.M., Townsend,
J.R., Mangine, G.R., Robinson, E.H., McCormack, W.P., Fragala, M.S., & Stout,
J.R. (2014). Reliability of the Dynavision D2 for assessing reaction time
performance. Journal of Sports Science and Medicine, 13, 145-150.

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