A Sit Down – with Dr. Curt Baxstrom
This post appears as part of a series called Sit Down – candid conversations with real people detailing their journeys and experiences with Vision Therapy.
A Sit Down – with Dr. Curt Baxstrom
For the benefit of our readers, can you give us some information on your background, and explain how you became involved in Developmental Optometry?
I first introduced to Optometry while a 2nd grader when I got my first pair of glasses and realized how cool it might be to help others to see just like this. I followed that line of thought and graduated from PUCO in 1984 and during my third year some of us were watching Hill Street Blues together and up came a news spot on Dr. Robert Pepper who was doing VT with a group of high school athletes. It perked the interest in two of us as we’d started considering the life of asking which is better, 1 or 2? It had seemed to be a profession that had limitations in how one could people by solely changing visual acuity. But then following Bob’s news clip, we headed in to talk to him about what he did in Lake Oswego,OR. He presented a whole new aspect of how you can help others as an optometrist. During my 4th year VT rotation I was next exposed to Dr. Robert Michael Kaplan, with another twist on developmental vision care. My first experience with a patient who had esotropia changed my model dramatically. The 10yr old boy had two 14 week sessions of vision therapy and was still an amblyopic esotrope with no changes from his initial findings. I was thinking this might be one of those you send out for surgery. Robert kindly suggested there was more we could do and he proceeded to have me take the patient to the VT room where he had me instruct the patient to start jumping on a mini-tramp. I was shocked and confused why we were doing this(I had heard this VT advisor was on the strange side!). Nothing in my VT course said anything about a trampoline. After 3 minutes of jumping he had me have the patient look at me and his eyes were straight and this lasted for about 2-3 minutes. He then instructed me that my job over the next 14 weeks was to help the patient keep his eyes straight after he stopped jumping. That was the beginning of my interest in vestibular processing and how it can be used to supplement a VT program to make it more efficacious. After school I spent a week with Bob and that was the start of my career in this area.
I practiced in my hometown of Bremerton for 2 years realizing more every day I needed more. One of my next influences was Al Sutton,OD whom was writing on a variety of topics for OEP at the time and I was working on a Masters in Reading degree from Seattle Pacific University. My thesis project was actually using many of the tests Al was working with at the time and combining them with the Pepper Concentration profile. I continued to have more questions than answers about vision and learning and fortunately that was when Frank Belgau, PhD crossed my path and helped me to find an opportunity to join a VT practice in Fresno with Dr. Shaw Yorizane. Frank had taught at U of Houston in the VT/Perceptual department for years and continues to sell his “Learning Breakthrough Program” through www.balametrics.com . He was also an important figure in out local study group. Shaw really groomed me nightly as we’d be doing paperwork, sharing cases, talking about our experiences of the day with our patients. I wouldn’t be where I am today without the experiences we shared.
I next was getting a little homesick and decided it was time to move back home and try to start a VT only practice. That’s when I moved back to the Seattle area and that’s where I still stay today.
My interest early on was in vision and learning and we still do a lot of this work today. Then I started working more with OT’s and PT’s in our area, sharing patients. That’s when we brought one into our office and often cotreated patients. I learned a lot about the developmental needs of these kids and gleamed many valuable experiences. The next major jump was when the pediatric OT’s spoke with the rehabilitation OT’s about our work and they wanted me to come to the hospital and work with them. That took off very well and suddenly I found myself wanted by 5 hospital rehab units. That became a burden and eventually I dropped back to the main two in our area, which is where I spend my Friday afternoons. Evaluating and working with OT’s and rehabilitation patients with stroke, TBI and a wide array of other neurological conditions. The OT’s had instilled in me the importance of development and the vestibular system. That’s about the time Dr. Jason Clopton and I met at COVD and we hit it off with guns a blazing. Jason’s wife Heidi is a pediatric OT and we began a unique relationship that eventually led us to teaching a 2 day course on vestibular processing in vision therapy. He was the first OD I’d crossed paths with that really took a great deal of interest in the value of adding vestibular input to a VT program. We continue today teaching a variety of other courses and almost daily we have discussions on more complicated cases and concepts. It seems every new answer we have, we simply have more questions. He is my twin brother of a different mother! I can tell you it seems like just yesterday I graduated from PUCO (actually 30 years now). The growth of what we do continues to expand and our ability to help our patients reach their maximum potential continues to escalate.
What is NORA?
NORA is the Neuro-Optometric Rehabilitation Association, International which is a group of committed individuals from various disciplines focusing on advancing the art and science of rehabilitation for the neurologically challenged patient. The main goals are to help facilitate education and experiences that provide our patients with the best possible outcomes following a neurological event. This is provided through our annual meeting in which we have two days of clinical skills and also 2 days of general meeting where we have a wide variety of speakers on different topics in visual rehabilitation.
You serve on the Board of Directors of NORA and currently sit as Vice President of the organization. Why was it so important to you to participate in NORA’s infrastructure?
I believe that each of us has a responsibility to help the developmental optometry community as a whole so that we can all continue to grow and prosper. Within the developmental optometry community the value of the whole is much more than the sum of its parts. As we each provide our time and efforts to all of the organizations including NORA, COVD, OEP and CSO, we all reap many benefits both short term and more importantly for the long term.
Initially I was asked by several NORA members to become involved and one of the first things I was asked to do was to help put together the annual meeting in Seattle in 2000. From there things have continued to evolve.
I can tell you I’ve reaped many benefits from NORA regarding my knowledge base and developing relationships with colleagues that continue to help me grow as an individual and a clinician. Participating in NORA’s infrastructure is simply an opportunity for me to try to give back to the organization. Under the guidance of our current president Dr. Carl Garbus, NORA has grown leaps and bounds. We have surpassed our old record of 176 attendees and grown to over 250 each of the past two years. This year will be a challenge as I’ll be following in the footsteps of Carl who along with his wife Jenny have really moved us in a very positive direction. They have put a lot of time and energy during the past four years and our NORA members have a lot to be thankful for. But even more importantly, more patients are receiving neurorehabilitation optometric care than ever before.
On the day this interview posts, NORA’s Annual Meeting will be in full swing in Cary, North Carolina. What exciting topics will be discussed this year?
As many know, we provide a clinical skills curriculum for people to learn about neuro-optometric rehabilitation. The last 3 years we’ve also added an “advanced” curriculum that lasts the first two days for those who want more depth in particular areas. We’ve had primitive reflexes and yoked prism previously and this year we have ImPact doing a 1 day presentation which is probably the most popular Concussion Management program. Dr. DeAnn Fitzgerald is doing a second day on implementation including evaluation and management of ImPact in her office. So the emphasis this year is on concussions. The general meeting has a variety of topics and you can go to www.nora.cc for the complete program and list. The other main topic we’re looking at is hemianopsia and we are fortunate to have Dr. David Lewerenz speak on the use of prism systems and Imelda Llanos,OTR to speak from an OT perspective on what therapy procedures are helpful for those with hemianopsia.
How can readers support NORA’s mission?
First become a member! Secondly volunteer your time to the board. Let us know your thoughts and what you’d like to see us do more of. Being a volunteer organization we are a reflection of our membership and as you can tell by our past few years, we’re growing. We are also fortunate to have a new Executive Director, Angela Gosling, who has been helping us to get all of our projects in line. She’s a great organizer and is always looking at new ways to help us grow. I’d recommend you and all other members at the meeting this coming weekend to be sure to introduce yourself to her.
My friend Cavin Balaster was interviewed here several months back and has since been named the keynote speaker for this year’s annual meeting for NORA. What are your thoughts on Cavin’s story, and why is it important that his story be shared with the masses?
One of our NORA members, Dr. Denise Smith was one of his providers. His story is important for us to share with others as it demonstrates the importance of Optometric care in the rehabilitation of patients who suffer an acquired brain injury. We should all support his book that he is writing about his story. We’re looking forward to it as it becomes available. This means sharing it with all of our colleagues in the rehabilitation community including physiatrists, OT’s, PT’s, Speech therapists, etc..
We invited Cavin as a TBI survivor because it is important to keep our minds open to how many ways our work can provide benefits to the patient. NOR doesn’t treat conditions, it treats patients and their lives. Our work does so much more than simply address the diagnoses we use in each individual case. We simply change lives!
What constitutes a brain injury and what are some of the symptoms one may experience in the days and weeks that follow?
Terminology sometimes is confusing, but the term that seems to take precedence now is Acquired Brain Injury(ABI), which includes traumatic brain injury, strokes and many other neurological conditions.
There are many symptoms related to a brain injury. I’d recommend clicking to this link from the NORA website for more detailed information. With all of the public awareness of concussions, here’s a link to vision and concussions.
Several of our colleagues are working on developing a TBI questionnaire to use with out patients to help evaluate outcomes. The interesting thing to me though is that often patients seem to get WORSE, before they get better. What seems to happen as they are not able to recognize many of their dysfunctions, but as they get better they are more aware of them. Thus their symptoms tend to get worse, and then they improve and recover from that base.
Why is it that some brain injuries have such an impact and some are far less debilitating?
This question warrants much more than we have time to place here. As we know, the visual system is so pervasive throughout the brain and that an injury anywhere may have a visual component. There are many factors to consider: preexisiting conditions, size of the lesion, the location(brainstem, cortical, etc.), treatment of the medical condition(stroke), rehabilitation of the condition, etc. For example, a major middle cerebral bleed may need to be treated urgently including a possible craniotomy and drainage. This would clearly have some severe impact on recovery. Whereas a transient ischemic attack may be self limiting and not likely to provide as much impact.
How can Vision Therapy be effective in treating someone who has suffered a Traumatic Brain Injury?
What first must be determined are the visual needs of the patient. Once assessed, then therapy may be addressed to help provide an opportunity for the patient to return to work, play and school. When I first started in this area over 20 years ago the treatment of diplopia was to monocularly patch. Simply do a pen and cap test and observe the problems with localization when one monocularly patches. Think about how this affects walking and judging things on the floor. This really puts the patient into a higher fall risk. Let’s say though the patient has a left cranial nerve 6 paresis with diplopia in left gaze. Instead of monocularly patching the left eye, one might use a right nasal sector occlusion to eliminate diplopia into the affected field(left), and simultaneously provides an opportunity for one to recover ocular motor control into left gaze with the left eye. The patient also maintains binocular vision near midline and to the right. I sometimes share with our OT’s and PT’s that monocular patching is similar to taking a patient who has a hemiplegia and instead of trying to first rehabilitate the loss, cast that side of the body so they can stand. They understand function which is what we’re always looking for when treating our patients.
Ideally, how soon after a Traumatic Brain Injury should a patient begin Vision Therapy?
In my mind, vision therapy is not an isolatable procedure. It should look at and address prevention, rehabilitation and enhancement. I used to suggest that we evaluate the patient as soon as we can. In our hospitals the ophthalmologists preferred the “wait and see in a year” model. I think it is clearly time that we take an active look at prevention in this population, so this should include assessing patients beforehand. This is one of the reasons why we’re offering ImPact testing this year. This suggests that patients should consider a concussion evaluation before entering sports. This could be an ImPact or Scat concussion evaluation and an optometric evaluation beforehand including ocular motor testing using King Devick or DEM. That would be probably the ideal situation.
If we have a patient in our rehabilitation units that has any visual concerns, they are always evaluated now because vision could simply be a missing piece of the puzzle. Otherwise the patient may not improve in their rehabilitation as quickly and as completely as they might otherwise.
Of late, a spotlight has been shining on sports related head injuries and the “on the field” diagnosis of these symptoms. How important do you feel these advancements are in protecting athletes of all ages?
They are CRITICAL. This can include a variety of different tests, etc.. The problem is we do not have a clear view of exactly what should be done or what is needed. One of my patients is Zachary Lystedt, who after his football injuries in junior high became a leader in this area of “return to play”. The law started here in Washington and has now seen its way across the states. I last heard it was at 43 states with more pending. It is the return to play law following a concussion where the patient has to have a physician ok the player to return to play. This should clearly be passed in all states.
Outside of optometry, what resources do you recommend to support the families of those with a Traumatic Brain Injury?
Most of our patients come to us because of referrals from other resources and providers. We use a variety of resources based upon need. This means sometimes a patient has a complex case and many providers who may not seem to be all on the same page and the patient is frustrated trying to figure out exactly what to do. This is where physiatrists can be helpful as their expertise is in looking at the big picture and treating the patient as a whole. They are wonderful to work with because they understand function and recovery. Besides providers in our areas for specific needs, we also have a number of TBI support groups that center around the hospital and rehab centers. These are often great for our patients so they can realize others have similar concerns, and together they can often help each other through the process of rehabilitation.
When Jared Torgerson COVT was interviewed here, the Seattle Seahawks had just won the Superbowl and Jared was offered the opportunity to gloat. So all is fair, are you a Seahawks fan?
Certainly I am! I still have my poster of the first team in 1977. The Seahawks organization has clearly developed a good model to work on developing a sustainable successful team. The word around the league is that many teams are trying to copy us. Several Denver colleagues asked me to bet them on the super bowl and I gladly accepted their offers. At NORA next week I will be accepting their payment of a nice Gentleman Jack and Seven. Another colleague suggested that we had beaten Denver so badly that a full bottle of Gentleman Jack should be in order! My heart though is probably more with the Seattle Sounders, our MLS team where I am a season ticket holder. I’m waiting for them to make it to the MLS Cup!!!
Some Closing Thoughts – A great thanks to Dr. Baxstrom for this interview. His contributions to Developmental Optometry and his passion for helping his patients continue to be inspiring. Please join me in wishing Dr. Baxstrom and his family the absolute best! 🙂