Convergence Tasks for Therapists

The Z axis

As therapists, we recognize the importance of mid-line crossing to help with primitive reflexes.  Reaching lateral outside of the base of support challenges balance and posture.

But to exercise convergence, the therapist must turn their favorite activity into the “Z axis”. This axis is the near-far axis, (referred to as the Z axis in vision) and challenges the convergence and accommodation system.  Many of our favorite activities can be modified just by turning them, to help strengthen the near vision system.

Simple convergence strengthening activities

Clothespins are great therapy tool, strengthening pinch for writing and other tasks. Having a child reach to a distance to retrieve the clothespin then hanging the clothespin on a near string can can help with convergence and divergence. The proprioceptive input of the hand hanging the clothespin on the string will cue the eyes to converge to a point.

The swing adds vestibular and proprioception to the convergence and divergence in this video.

In my clinic, I also use a cup with a straw that patients then put toothpicks in. This task can be graded by moving the cup closer to the child’s face.  This is task also made more difficult by not allowing the kiddo to touch the straw, removing the proprioceptive input,  forcing the eyes to guide the hand more accurately.

Amazing creative therapists

Cheerios on a Straw

In the task, the patient puts cheerios on a small coffee stirrer. The hand working at the end of the straw does a great job cuing the eyes to converge. Just make sure the straw stays in at mid-line.

Ball in a Tube

In this task, a 4 ft florescent bulb protector ($4 at Home Depot) is cut in half with a ping pong ball put inside. I then placed stickers on top of the tube. The patient has to align the ping pong ball under the the sticker. In standing? Even better. Balancing on a balance board? Even better!!!

As a bonus, the scrap end of the tube become a great “light saber” for popping bubbles to work on tracking and eye hand coordination.

Thanks to therapists that I have met

The weeks I spend traveling are exhausting but the energy of the people I met help me stay motivated. Thank you to all the therapists and teachers and others, that I have met.

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“Can eye movement problems be related to torticollis?”

Ocular Torticollis

Torticollis can be caused by several things. Delays or problems in the integral development of muscle tone, the vestibular system and propreioception can all be causes.  Eye alignment, nystagmus and acuity problems can also affect head position.  When vision is the primary cause for torticollis, it is referred to as ocular torticollis.  One study found 20% of torticollis related to ocular problems. (1)

Eye alignment

Head tilts and head turns are common signs of eye alignment problems. Deviations between eyes in the horizontal plane (hyper- or hypo- tropia) can cause head tilts in the brains attempt to see a single, fused image. Head turns (rotation) to right or left can be caused by strabismus (eso- or exo- tropia). Again, the brain turns the head in attempt to not see double. Other more complex movement patterns can also cause head position and posture problems.

Nystagmus

Nystagmus is an involuntary movement of the eyes. This is generally associated with a neurological problem. They can be congenital or acquired. Many times, patients with a nystagmus will turn their head to find the point at which the nystagmus stops. This point, called the “null point” allows for improved vision for the patient.

Acuity problems

Astigmatism, a condition in which the eyeball is not perfecting round but more football shaped, can also cause visual acuity problems that might facilitate a head tilt in order to improve vision.

Eye Exam

Every child should have their first eye exam at 6 months (per AOA recommendations). A through eye exam that includes a binocular vision exam would find eye alignment problems most likely to cause ocular torticollis.  If treating a patient with torticollis of unknown cause, a binocular vision exam could be helpful in identify the problem. Frequently, prisms and lens can be prescribed that can help reduce the torticollis.

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Worth 4 Dot

Worth 4 Dot

The worth 4 dot is simple tool for assessing suppression and fusion. The results oworth4dotf the quick assessment can give us clues to the function of the eyes. The worth 4 dot (W4D) test is is made up of a pair of red-green glasses and light with 4 dots, 2 green, one red and one white.

The patient puts on the glasses and the light in placed near (40cm or less) and asked how many lights they see.  It is then moved to distance (1 M) and asked once again how many lights are seen.

W4D Responses

There are 4 appropriate responses. Other responses should be considered a failure of the patient to understand the instructions.

  1. 4 lights, near and/or far indicate using both eyes. I will ask if the lights are moving or not to see if the fusion is steady.
  2. 3 lights or two lights- three light indicates suppression of one eye. Which eye depends on the red green arrange of the particular test one is using. They may suppress at near or far or both, so an answer of 3 close and 2 far would be appropriate.
  3. 5 lights- a response of 5 lights indicates the patient is having double vision at the range. It may be near or far or both.

The W4D is usually the first test I do as it gives me early clues what to look for as I begin looking at eye movements. This test can also indicate how a patient may do on stereopsis testing as suppression of of an eye could me reduced stereopsis.

Getting a Worth 4 Dot

Worth 4 dot is available from Bernell.com. There are several version but the idea is the same for all.

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The Brock String

The Brock String

The humble Brock consists of a length of string (from 3 to 10 ft) with a series of beads (from 3 to 5 beads) placed at various intervals. This simple instrument is powerful tools in teaching binocular vision skills.  While the configurations vary, it is elegantly simple and effective in teaching the brain how to make the eyes convergence.

How the use a Brock string

The 3 ft string is generally sufficient unless working with an athlete then a longer string my be needed. Four or five beads make for enough targets to be useful.

  1. With the beads evenly spaced (closest bead at about 2cm, furthest about 40 cm), have the patient hold one end of brock string to their nose.
  2. The therapist holds the string tight and angled slightly downward.
  3. Have the patient fixate on one of the further beads to begin. The patient should see one bead (indicating focus to a single point) and two strings meeting at the front of the bead (indicating both eyes are working together. It should look like the picture below.
  4.  Have the patient alternate from bead to bead, working closer and back to exercise the convergence muscles. Look for difficulty with maintaining the fixation as the muscle fatigue.

Brock-String-4-300x65

Here is video of a brock string in action. Notice the the “bobbles” as she moves from bead to bead. This is an indication of weakness. When they see it correctly, the eyes get very still.

Why does this work?

The brock string takes advantage of “physiologic diplopia”. The eyes can only focus clearly on single point with all other things within the viewing area seen as double. This is a normal way for our eyes to work. The brock string uses this physiologic diplopia as a cue to the let brain know the eyes are working together correctly.

Remember, before the brock string, check for full extra ocular movements and exercise the eyes separately.

Brock strings are easy to make and make a great home program addition.

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The Binocular Vision Exam

The Child’s Special Visual System

Children’s eyes are amazing. They bring the world to an eager child and facilitate development of many skills.  The visual world influences posture and gait, fine motor development, letter recognition on to reading skills and many other areas.  The importance of good vision cannot be over stated.

The Pediatric vision exam

The vision exam for a child should include assessments not generally not performed on adults. Check out this post first to understand how we see up close. 

  • Cyclopelgic Dilation and Refraction- This allows for the doctor to completely exam the retina of a child for optic nerve problems and other congenital problems that child may have. The cyclopelgic dilation also relaxes the ciliary muscles which control accommodation (focusing of the lens within the eye). This allows the doctor to exam the true refractive error of the eye which can frequently be corrected by the accommodation of the lens.  This should be considered mandatory once a year.
  • Near Point of Convergence – This brief assessment allows for the doctor to assess how how well the eyes are working together when seeing up close.
  • Measured cover test- A cover test reveals the amount of effort needed for the eyes to maintain their position. It also shows subtle eye movement problems like strabismus.
  • Retinoscopy – in this assessment, the doctor can get an objective measurement of refractive error. This eliminates communication problems some children may have and makes for the most accurate solution for a child;s visual acuity.

Better or Worse

General optometrists and opthamologists may or may not perform these tests.  Without them, an important part of the assessment of a child’s vision has been left out. Eye movements can cause delays in gross and fine motor development and decreased reading performance and difficulty in sports, like hitting or catching a baseball.

Look for doctors that advertise being pediatric or binocular vision specialist. Look for doctors that members of the College of Visual Development or the Neuro – Optometric Vision Association.  These are doctors that specialized in the assessment of binocular vision skills.

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Visual Motor Integration

Visual Motor Integration and Eye Movements

Visual motor integration is the use of visual information to make a motor plan. These “motor plans” include things like balance, walking in a straight line, handwriting and solving puzzles like mazes and parquetry patterns.

In the earliest days of baby’s life, they see an item across the room. A parent, a toy or a favorite snack can ignite a spark to move. This is a developmentally early example of vision facilitating a motor plan. When a child has poor vision, they tend to not explore their environment and consequently show decreased gross motor skills. As children learn to write, visual motor integration plays an important part as the child sees the letter then copies the letter, a fine motor action.

Visual Motor Integration Problems

The visual motor process starts with vision. The child must see the letters accurately in order to copy them accurately. The child then must have adequate strength and coordination to execute the task. Errors in visual motor integration can be related to difficulty with the visual input or motor output of the equation. Error of the motor part tend to be quickly identified by occupational therapists as perhaps weak 3 point pinch during hand writing or weak leg muscles while walking a balance beam. But what about the visual input? What if this child has poor eye teaming or reduced vision?

Putting the Visual in Visual Motor

Imagine someone attempting to identify a coin by only using their sense of touch, only there is glove on their hand. This would be very difficult and the person would most likely be incorrect. Does this person have a problem processing tactile information? Of course not! They have not gathered accurate information and therefore will not process to the correct result.

The same thing happens when a child with vision problems has their visual motor integration tested. The child always has reduced visual motor integration because they are not getting accurate visual information.

Visual Motor Assessment and Treatment

The most consistent functional problem seen in children with eye teaming problems is below age appropriate visual motor integration. There are several good tools for assessing visual motor integration including the Test of Visual Motor Skills , Full Range Test of Visual Motor Skills, and Beery Visual Motor Integration test. These all are standardized test and are part of any good occupational therapist’s assessment.

Children with visual motor integration problems will have reduced balance and difficulty with handwriting and copying from the board. They have difficulty with visual puzzles and finding the visual differences in shapes and drawing. Treatment of the deficits will be very difficult if the child is having eye teaming or other vision problems.

Here are some great sources for visual motor activities:

Tools to Grow     Your Therapy Source    Eye Can Learn

There are some iPad Apps too!!

My Mosaic has kids make pictures moving colored dots.

The Matrix Games has several games for putting shapes together.

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ADHD and Eye Movements

ADHD and Eye Movements

There is much research concerning the link between eye movements and ADHD. Researchers consistently find specific eye movement behaviors associated with ADHD. But how does this research help in the clinic?

ADHD and Saccades

Much of the ADHD/Eye movement research has focused on the quick, exploratory eye movements called saccades. Children diagnosed with ADHD show saccade accuracy consistent with their peers. They are able to quickly and accurately look to a new target in the environment. When instructed not to look a target (anti-saccades), children with ADHD have a more difficult time NOT looking at the stimulus (1). Reading is a series of quick fixations and saccades that affects reading speed. These saccades improves reading fluency in children(2) . Children with ADHD also show reduced tracking ability which further affects reading fluency (3)  (4).

Near Vision and ADHD

Convergence Insufficiency, an eye movement disorder affecting one’s ability to maintain clear near vision, is found at three times the rate in ADHD children compared to those not diagnosed with ADHD(5).  A study also shows that children with symptomatic convergence insufficiency score higher (more negative behaviors) on an academic behavior scale then those children diagnosed with ADHD (7). So convergence problems can be associated with ADHD-like behavior problems.

ADHD and Optometry

Optometry is aware of the link between eye movements, behavior and academic performance. ADHD symptoms can mimic the behavioral signs of eye movement problems, even when a child is unable to vocalize the vision problems he is has having. Treatment of convergence problems is also known to reduce the symptoms of ADHD reported by parents (6). Treating saccade and tracking problems also helps to improve reading fluency and improve academic performance.

Only a complete evaluation by an optometrist that specializes in eye movement problems can help identify these problems that could be limiting performance in a child with ADHD. Treatment of these problems with in-office vision therapy can help improve a child’s academic performance.

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