Case Studies Show Success In OT-OD Treatment Plans

By Shannon Downing-Baum
And Dominick Maino

Special to ADVANCE

The American Optometric Association notes that 85 percent of all learning is mediated by the visual system. If this system is dysfunctional, how well could you receive and then process information? Not very well.

What effect does that have on the learning process? The question has mostly been left up to educators to answer, and therapists may feel that it should be addressed by medical and educational personnel other than themselves. But therapists can help provide solutions for dysfunctional learners, with the assistance of the developmental and behavioral optometrist.

In all stages of development, including older adults, oculomotor dysfunction may be addressed in a behavioral vision approach that can enhance ability to learn and improve the quality of life of an individual with a disability.

Vision therapy developed in the field of behavioral optometry can be successfully combined with multi-sensorimotor techniques to provide neurological connections for previously blocked pathways.

OTs and ODs (doctors of optometry) should work together to provide such treatment for the benefit of their patients and clients.

For instance, an individual with traumatic brain injury may have double vision or significantly reduced eyesight due to the trauma. The behavioral optometrist can then prescribe special lenses that can reduce or eliminate the diplopia and enhance any remaining eyesight. Vision therapy may then be recommended to take place either in the optometrist's office or in conjunction with OT sessions in which the patient is already involved, to remediate or develop adaptive mechanisms of interacting with the environment.

Following are some case studies to illustrate the point.

J.P. is a 10-year-old with reading and handwriting (three-year delay) impairment, born to a mother who continues to experience similar problems. She brought him to the hospital rehabilitation clinic for an OT evaluation. He was given a diagnosis of LD by a physician, and the school system felt the boy was not responsive to its supplemental reading assistance program. He did not qualify for school OT intervention.

J.P. scored within normal limits on the sensory integration checklist. His fine/ gross motor skills and math skills are age appropriate. All of J.P.'s oculomotor skills were functional as assessed by an OT vision screening and subsequent evaluation by an optometrist, except for speed of tracking pursuits as tested by the King-Devick visual tracking test.

J.P.'s scores on the Woodcock-Johnson cognitive battery indicated significant auditory and visual memory difficulty. The therapist observed that the boy was virtually unable to abstractly visualize: he could not describe objects taken out of direct view, especially in sequence. J.P. was most responsive to sensorimotor tasks that took him out of the usual table/chair positioning of the classroom.

To attempt to advance his academic ability, the therapist asked J.P. to stand in a dark room, shine a flashlight on two objects, switch off the light and describe details of the objects. He was asked to remember details of pictures for homework.

J.P. was placed prone in a net or platform swing and rotated while he looked for puzzle-piece letters on the floor, which he placed in alphabetical sequence in a form board. He was asked to remember two letters in sequence and picture them in his mind with his eyes closed before he looked for them. Initially, J.P. could not recognize or correctly form several letters, making many reversal errors, nor state the alphabet in sequence. He was immediately asked to form the letters found with his finger, in a tactilely stimulating medium such as modeling clay, sand or shaving cream.

Standing on a tiltboard, J.P. threw a ball at letters which he wrote randomly on a blackboard in alphabetical sequence. Using an electronic turntable, he pointed to and said the names of the letters as they rotated in alphabetical sequence or while spelling out words he read from cards posted several feet away.

J.P. was given a wooden stick on which are written letters in alphabetical order. On the wall is posted a sheet with simple words written large enough to see from a few feet away. Hanging from the ceiling in a small ball suspended from a string, J.P. hit the letters on the stick as he spelled the words from the sheet, trying to remember two to three letters of the word at a time.

J.P. had homework. He was given two small tongue depressors with the alphabet written on them: A-Z on one side, Z-A on the other. J.P. was then asked to hold the sticks several inches apart and shift his gaze between them, naming the letters. Using saccade papers--pages with letters placed on the left/right sides--J.P. was asked to say the letters in sequence as quickly as possible. Using pages made up with letter jumbles, he was asked to find the alphabet and spell words given while systematically tracking left to right, and down the page.

After three months of treatment, J.P. scored significantly higher on the cognitive test in school, and his mother and teachers felt he had made significant gains in academic ability, particularly in visual memory skills.

D.W. is a nine-year old client who was referred to occupational therapy when he was 7 years old for help with sensory integration and learning problems.

An initial evaluation revealed several sensory problems, including vestibular, auditory and visual processing difficulties.

When D.W.'s visual problems were evaluated by a developmental optometrist, he found normal acuity; exophoria (inappropriate alignment of the eyes); poor convergence skills; dysfunctional tracking ability; poor ability to jump quickly between small pictures on a page; difficulty in quickly adjusting his focusing between close and distant objects (accommodation flexibility); a tendency to avoid close-up work, including tabletop manipulates and worksheets; limited binocular stereopsis as tested by the Stereo-Fly test; poor motoric formation of shapes as tested by the Beery Visual Motor Integration test; poor performance on the Test of Visual Perceptual Skills (Morrison-Gardner)--particularly in visual memory; fair number recognition; poor letter recognition; and poor motoric formation of both.

D.W. also had been evaluated by a neurologist, who had ruled out attention deficit disorder as a contributing factor. D.W. received OT services in his classroom and help from a reading specialist. He generally appeared to be a passive, shy child with poor self-esteem who was nonetheless cooperative and interested in learning.

D.W.'s parents were very concerned about his poor progress in school, particularly his father who described having had similar problems at D.W.'s age. Because he had not received the assistance he needed as a child, D.W.'s father was determined to provide such assistance to his son.

D.W. was in OT treatment for two years. He was initially treated using vestibular, kinesthetic, proprioceptive and tactile stimuli combined with spatial visual input. D.W. appeared to need a movement component even in static table work.

Alphanumeric and motor formation and recognition were accomplished by using ball games, puzzles, flashlights, flags and computers--anything but just sitting and writing.

As D.W. gained confidence and mastery with sensory integration, visual therapy components such as fixations (saccade training), letter tracking, convergence, accommodation flexibility, binocular fusion, and visual memory tasks were added to his treatment program to address his identified visual deficits.

Combining sensory integration principles with vision therapy techniques proved more effective in fulfilling D.W.'s needs than either approach alone. Speech therapy was added after the first year to help integrate language processing and reading.

D.W. improved in all of his identified deficit areas, was functioning in the low-average range academically and was reading within normal limits for his age ability upon discharge from treatment.

* About the authors: Shannon Downing-Baum, MS, OTR, a practicing therapist of more than 14 years, received her certification as a vision therapist in 1994, from the College of Optometrists in Vision Development. Dominick Maino, OD, is a specialist in the areas of pediatrics, binocular vision function and visual problems of children with developmental disabilities.

* For more information, contact Shannon at Internet address 70403.3264@compuserve.com or Dr. Maino at dmaino@juno.com. Other resources include the College of optometrists in Vision Development P.O. Box 285, Chula Vista, CA 92012.