Frequently Asked Questions - Visual Therapy
The most exciting treatment alternative available to the behavioral optometrist is vision therapy (VT). This is a treatment program in which the optometrist provides the patient the opportunity to learn and develop those abilities that either were not present or were poorly developed in the patient's overall profile of visual abilities. Vision therapy is a step-by-step, development-based series of activities and procedures that the patient practices over time. The therapy is designed to facilitate the development of a more efficient and comprehensive visual process.
- Why do you do VT Progress Evaluations and what kinds of information will we get as a result?
- Visual Therapy
- Can we help by doing any of the visual therapy in the classroom?
- Will your work specifically address pencil grip and writing posture?
- Will your work address posture at all?
- Are timed tests a problem and if so, when should I expect this to cease being a problem?
- When might I see changes in attention?
- How long until reading changes and what types of changes may I see?
- Within what kind of time frame should I expect to see change?
- What is Visual Therapy?
- Now that the problem has been identified what will happen?
- How do children acquire skill in the use of their visual abilities?
- What is the visual process and how do we use it?
The name of these visits that occur after each group of eight therapy sessions is a bit misleading. As patients progress through their vision therapy both they and my staff are getting direct feedback as to the level of progress being made. We use a curriculum model of providing vision therapy. This refers to the fact that based on the kinds of unmet visual needs you present with I will have either selected an appropriate curriculum (sequence of activities in a proscribed order) program from our standard selections or customized a curriculum for your special needs. Based on the length estimate I gave you at the first visit we have a shared expectation of how long it will take to work through your curriculum. Each week we can see if you have mastered the prior weeks assignments and are ready to move on or if you require additional time to master these activities. As you move through the curriculum you will get a sense of accomplishment and will know you are making progress. As well, you will note many things in your life that are changing, as your needs are beginning to be met. For example it is not unusual for people who have come in with headaches when doing sustained near concentrated tasks to have those headaches be gone by the first 8-week progress evaluation. So if you and my staff and I know you are making progress why do we need to get together once every 8 weeks? The primary purpose is for me to take some independent objective measures to be sure that the curriculum we have chosen to work on is still most appropriate. Another aspect of the testing is to make sure that any lenses that you have are indeed correct. Many times lenses are given to help treat the underlying problem but as the therapy progresses their role changes from treatment to helping to reduce visual stress. In some cases the actual prescription will need to be changed and at others the form of the lens (ex: single vision lens to a bifocal) may need to occur. Finally, as your life demands change you may identify additional needs that we may be able to address which might require me to alter the curriculum we have set up for you. All this occurs during the progress examination. After you have completed your vision therapy, I generally see you at one, three and six months to make sure that all gains are holding and again that you have the correct lenses on. Vision therapy plants a seed. And through continued use, it generally continues to grow and develop well after we have finished office-centered therapy. Many people continue to make excellent gains during this post-therapy period.
Some vision problems cannot be treated adequately with just glasses or contact lenses, and are best resolved through a program of vision therapy. Over 45% of the space in our office is devoted to this unique service. Our vision therapists are all well trained professionals who function to implement individually prescribed vision therapy programs, usually scheduled in-office on a weekly basis.
Vision therapy utilizes various procedures to aid eye-mind-body coordination. This enables people to use their vision more effectively. Typical improvements noted as a result of a vision therapy program are clearer vision, improved memory, increased interest in reading, along with better comprehension, endurance and speed. Vision therapy also helps focusing problems, tired eyes, headaches, fatigue following visual tasks, light sensitivity, and aids depth perception, night vision and peripheral vision. It is the most effective treatment for eye turns and for “lazy” eye. The multi-sensory vision therapy that we use improves integration of vision with gross and fine motor abilities, speech and hearing, and rhythm and timing abilities.
A patient may enter into vision therapy to cure a number of different types of visual difficulties or to simply enhance their visual performance in some way. Some of the reasons our patients choose vision therapy are:
- Control and treatment of near point stress
- Learning related visual problems
- Eye turns, strabismus
- Lazy eye, amblyopia
- Sports vision enhancement
- Reduction of job related visual problems
- Improvement of near point concentration
- Improvement in visual efficiency
Our program includes a once-weekly in-office 50-minute session of treatment with 15-20 minutes of home practice on the days that the child does not come to the office. Of course some more home practice may be helpful but we find that the 15-20 minutes assigned is adequate. We don’t see a need to use your valuable class time to address these concerns for an individual child.
Now if you should want to look for group activities, particularly in the early grades (K-3) to do with your children, I can highly recommend the book, "Thinking Goes to School" by Furth and Wachs. This is published by Oxford Press and is available at www.oep.org. This book details an educational curriculum and program for the early grades based on the Piagetian principles of learning.
If the only problem a child presents with is a pencil grip and writing posture, we will often make a referral for occupational therapy. However, many children that require visual therapy also present with pencil grip and writing posture problems. If the parent wants us to address this we will deal with the sensory motor aspects of holding a pencil and sitting at a table early in the therapy. Towards the end of therapy we then address how to apply these new sensory motor skills to handwriting. In most instances the sensory motor skills need to be practiced at a fundamental level for several months before they can be applied directly to handwriting.
Many children with binocular problems (problems coordinating the use of both eyes together) are constantly shifting postures (squirming in their seats, etc.) in hope of either (1) reducing tension in the body coming from excess effort going into trying to keep the eyes working together or (2) hoping (subconsciously of course), to find a posture that physically blocks one of the eyes thereby greatly reducing the amount of effort needed to work.
As the child’s binocular problems are addressed the need to keep changing postures or to block an eye is reduced or eliminated. Thus, the range of postures assumed and the frequency of changes of posture are both reduced without directly attempting to work on posture. These changes are often noted to occur in the same time frame as the fixation and tracking changes.
Many children with learning related visual problems fall apart when put in timed situations. The added pressure of having to work fast may be the straw that breaks the camel’s back, causing many of these children to "melt down". During the first 8-10 weeks we are working to build fundamental visual abilities. From that point on, although more skill building and elaboration are being done, we shift emphasis to being able to multitask and to perform under pressure.
This aspect of treatment is aided by the use of a stop watch. A number of activities are timed and emphasis on some activities is shifted away from perfection to speed. Some errors are accepted in order to get the child moving. Once moving, then the emphasis shifts back to increased accuracy and then back to faster speeds. These cycles are built into many of the visual therapy activities all the way to using guided reading in the last 8-10 weeks of treatment. Here a moving window flies over text to be read about 20-30 words per minute faster than the speed at which the child is currently reading. These sessions of being pulled over text a bit faster than is comfortable pay great dividends. It also reduces the number of regressions in text (going back to the left within a line of text to reread a section) because the window only moves forward and does not allow for regressions to be of any help when reading.
So the bottom line here is that many of these children have trouble with completing work on time and when time pressures are added they may crumble. However, vision therapy specifically targets this and most children make very quick changes here. Generally from 4-6 months into treatment timing issues are no longer a concern.
Some children show this right away, but this is not to be expected. Typically the first change in the ability to sustain visual attention on near tasks begins around the 8th to 10th session of their treatment. Certainly by the 16th session or about four months into treatment I would expect the child to be attending much better than before, assuming of course that this was a problem before.
Reading is a complex process that is dependent on many visual abilities as well as a host of other skills. Much of the early emphasis in the visual therapy programs is aimed at the fundamental visual abilities. These foundational skills are necessary to build on, but often do not have an immediate effect on improving reading performance. Early on, the major effects might be that the child can stay on task for a longer period of time before tiring.
A major developmental hurdle, already discussed, is learning to move the eyes only when shifting visual attention from one place in space to another. Once this has been achieved we often see renewed interest in near tasks that involve sustained use of vision for deriving meaning. The fact that the child can now do this kind of task often helps them feel better about themselves, and early changes in reading may not be directly from the actual visual therapy, but indirectly from the changes in the child’s self-image and feeling that they are not dumb, that a real problem had been found and that it is being addressed.
As the therapy progresses we often see a pick up in the fluency of reading at their current instructional level. Mechanically we see the child begin to take in a larger perceptual chunk, resulting in them not needing to stop so many times with their eyes per unit of text. Because less effort is needed to keep their place, to keep the print clear, and to plan where to go next, as well as keeping both eyes directed accurately so that their inputs are complementary, more of the child is left to learn from the experience.
Over time we see a consolidation of gains at a level of reading material followed by a non-linear jump to a new demand level. When that happens there is a short period of time when the mechanics seem to make a downturn. This is because it takes more thought, reflection and some conscious effort to decode new words and to find the appropriate meaning in more complex contexts at the new level. Over time this too becomes consolidated, with a commensurate period of time of improvement in the mechanics again. This continues cyclically during the course of treatment as well as continuing for many months after treatment has been completed. This can also be seen in normally developing readers at the appropriate developmental time.
To recap, we first often see improvements that are more secondary to attitude differences than to actual treatment effects. Once the "eye movement free of the rest of the body" target has been achieved there is often a new ability to sustain near centered visual attention, which can be seen in renewed interest in close work. Then begins a cycle of change; beginning with improved mechanics at the current demand level and followed by a jump in the demand level that can be understood. During the early part of the jump to the new level the mechanics typically suffer for a finite period of time.
The time-frame for seeing change will vary with the degree of the problem, the age of the child, the intensity and regularity with which the home practice sessions are done , and many other factors. Generally, by the eighth week of visual therapy changes are beginning to be noticed by all. At first, these may only be that the child is staying on task a bit longer or doesn’t have to be restarted on homework assignments so many times. Often the child is beginning to notice things in their environment, many of which may have been there all the time but are just being recognized.
A major visual development step is the ability to track and fixate with eyes only. In cases where this was not present, I see this emerging by the 8-week progress evaluation. The visual therapy begins in free space with real physical objects and moves to working in the two-dimensional plane of paper or a blackboard at about this time. Since visual development follows this course one of the early signs of change is often in sports. The child with emerging spatial competency is more aware of where they are in space in relation to others and to objects and as a result of this they interact with these things more accurately and more consistently.
Visual therapy is a step-by-step developmental program designed to provide patients with the necessary meaningful experiences to acquire full use of their visual process. Visual therapy is based on Piagetian principles of learning, in which a series of graded problems are presented to a child under very controlled circumstances and then practiced for reinforcement.
Therapy in my office is done on a one-on-one basis for 50 minutes. Each session consists of four to five activities which are done for 8-10 minutes each. Then two to three of them are assigned for home practice. The most difficult aspect of being a therapist, as well as being a teacher, is to know exactly how demanding a particular activity should be. Too intense and the child may go into a "flight" pattern and avoid the activity or go passive and not fully engage in the activity. Too little intensity, where a child is asked to do something that they can already do, is a formula that simply wastes everyone’s time, effort and energy. My therapists are trained to adjust the demands of the activities to maximize the speed of improvement, but not at the cost of putting the child under too much stress.
A key aspect of therapy is the involvement of the parents as home therapists. We require from 15-20 minutes of practice or drill a day under the direct supervision of a home helper, who is most often the child’s parent.
The primary method of treating a visual development problem is to arrange conditions to provide the person with the necessary meaningful experiences to acquire these needed skills and abilities. The method whereby this is done is called vision therapy.
During the early phase we will be building foundation skills and abilities, which may not translate immediately into observable changes in the classroom. I view the course of a therapy program to consist of three phases. The first third of the therapy program helps the child acquire the fundamental visual skills and abilities. During the first third most symptoms such as headaches or blurred distance sight after doing close work are reduced or eliminated.
The middle third elaborates on those skills and abilities, so that when different life demands are encountered that may be similar but actually require slightly different skill sets, the child has the ability to shift from one application to another with ease.
The final third of treatment has two major purposes. The first is to automate the newly acquired skills and abilities so that the new skills are simply called on when needed without any conscious thought. The second is to help the child generalize the new skills so that as life throws new challenges, they can immediately call on what they have learned and make the necessary adjustments, again almost without conscious awareness of having done so.
We learn to use the visual process over time. Visual abilities develop as a result of life experiences that children have prior to entering school. We are a product of the environment we grow up in. Many of the skills and abilities we have began with meaningful life experiences as children. Visual skills and abilities are learned primarily through movement and interaction with our three-dimensional world. Novelty is critical for the emergence of a diverse set of skills and abilities.
A child with a limited set of experiences should not be expected to acquire skill merely as a result of surviving a certain number of years on this earth. Time alone does not cause development. Good development is the result of the appropriate meaningful experiences occurring at opportune times in a person’s life. Physiological maturity alone is not sufficient to guarantee proper development.
We cannot expect children who have never heard classical music to identify an oboe or a trumpet by their distinctive sounds. To do so they need the life experience of listening to these instruments in isolation and having someone properly identify the instruments for them. This needs to be repeated more than once to become a lasting skill.
Learning how to fixate on an object, shift visual attention from one point in the visual array to another, precisely align both eyes with ease for sustained periods of time, and shift attention from distance to near and back again are all developed skills. A child who has not had appropriate life experiences in meaningful ways may come to school without these requisite skills.
A behavioral optometric evaluation can be compared to taking an inventory of these visual abilities and skills and finding which are present and which may not yet have emerged. The lack of the emergence of these visual abilities no more represents a physical or physiological or mental deficit than it does in the music example above. In this situation, no one would diagnose a neurological music processing brain center in need of medication. There would be recognition that the life experiences necessary had not been encountered. (Of course there are isolated instances of such problems but these are few and far between.) The vast majority of what we see in clinical practice are visual development problems.
The visual process is the ability to derive meaning and direct action as triggered by light. The behavioral optometric use of the word vision or visual is very different than is seen by the majority of eye-care professionals and the public. Most people, when they think of what they do visually, think only of the clarity with which they see. They think of a trip to the eye doctor as a time to be reassured that their eyes are healthy and to allow for optical corrections in the form of glasses and/or contact lenses to be identified, prescribed and dispensed.
As a behavioral optometrist I do all this, but I also look at much more! From moment to moment we have things we are doing and things we want to accomplish. To do this we scan our environment with all of our senses, but the visual process leads this search and is responsible for building the spatial map of where we are in space, where our body parts are one relative to another and where the object or objects we are looking at, listening to or feeling are relative to us and relative to other things.
We then use this updated construction of reality to direct our actions. As seen from the perspective of a behavioral optometrist, when a clumsy movement or an inaccurate movement is made, it generally is not the fault of the motor system but is the fault of the guidance and control system, and is seen as a visual problem.
It has been said that most visual problems are problems of omission. This means that the information needed to properly identify and locate objects in space was there but it wasn’t taken in and used by the person. Due to a lack of inclusion of the necessary information, an error in the instructions sent to the motor systems results.
To do this well requires several fundamental visual abilities which include:
o The ability to move one’s eyes free of the rest of the body.
o The ability to easily shift fixation from one place to another.
o The ability to accurately point both eyes to the same place in space without excess effort and with a stable alignment. Unstable alignment often leads to the complaint of words moving on the page or momentary jumbling of the letters, or misalignment of numbers in math problems.
o The ability to sustain near-centered visual attention.