Behavioral optometry techniques can improve attention, memory

Certain patients with poor attention levels and memory may have not only physical dysfunctions, such as convergence insufficiency and accommodation error, but also problems with their visual system. Therefore, children with learning disabilities, adults suffering from head trauma and elderly patients losing their edge may all be well served with targeted vision therapy over refractive correction alone.

Vision therapy

“A significant aspect of our attention and memory comes from our vision,” Joel H. Warshowsky, OD, FAAO, FCOVD, said in an interview with Primary Care Optometry News. “According to Merriam-Webster, attention is an act of applying the mind to an object, and memory is the ability to store and process what is being remembered. The more efficient, effective and effortless the visual process, the more one has the ability to attend and remember.”

According to Warshowsky, any process a person’s brain performs has three distinct parts: input, organization and output. Input involves tracking, eye focus, eye coordination and lens prescription. Organization contains perceptual skills inclusive of memory storage. Output represents the desired behavior being promoted, given the visual stimuli.

“My opinion is that the easier it is to input visual information, the easier it is to store and remember,” Warshowsky said. “Therefore, activities that enhance motility, focus and eye coordination in conjunction with an optimal therapeutic lens prescription will result in the improvement of attention and memory.

“Additionally, we can directly incorporate tachistoscopic activities into any program designed to treat attention and memory,” he said.

Tachistoscopic activities flash numbers or letters at increasing speeds, training patients to remember more quickly and accurately what they are seeing.

These are the basics of vision therapy, Warshowsky said.

In vision therapy, sequential and directional optometric activities are used to redevelop the visual system, he said.

“These activities are designed to increase awareness of the visual process through intention to transform changes within the visual system,” Warshowsky said. “A common misconception of what we do is that we treat eye muscles. We’re actually treating the brain’s message to the eye muscles.

“Think of a dial radio that’s slightly off the station,” he explained. “The static sound we hear makes it difficult to understand what we are listening to. In the same way, the brain’s message appears as static to the eye muscles, not allowing them to function in the way we desire. We remediate that.”

Warshowsky defines remediation as a state of the visual system performing as if the dysfunction never existed. As the result of a treatment strategy and program, the dysfunction has resolved without regression, with continued growth and development of the patient’s sense of self, he said.

According to Paul A. Harris, OD, the visual process consists of deriving meaning from the environment, as triggered by light, then using that information to direct action within that environment as a result. Therefore, vision therapy, which improves the visual process, can alter a person’s ability to derive that meaning and apply it into action.

Nearpoint visual deficits

“There are several ways of looking at attention,” Joel N. Zaba, OD, MA, a vision consultant to education, told PCON. “If a person has an undiagnosed nearpoint visual problem, this can lead to difficulties in performing their nearpoint activities. Thus, these problems can cause symptoms such as taking a break, losing comprehension, avoiding reading, fatigue and short attention span.”

Near work, Zaba said, consists of any use of the eyes to focus at various near distances. Reading and writing occurs between 13 inches and 24 inches from the eye. Computer work occurs between 18 and 45 inches, depending on the patient’s visual environment.

A nearpoint visual deficit consists of a dysfunction in visual skills for nearpoint tasks, which are binocular vision, accommodation and eye motility, he said. A dysfunction related to any of these visual skills with any nearpoint range can cause fatigue, losing place, print blurring and double vision. This leads to a short attention span and lack of concentration.

These visual symptoms can be found at all ages and can result in problems in school or at work, Zaba said. Attention deficit hyperactivity disorder (ADHD) is a separate diagnosis, made by a physician and a psychologist, for a person who has a short attention span in almost every activity, he said.

“With all of the assistive technologies (tablets, cell phones, e-readers and desktop computers) available today for near activities, this generation is using its vision for near work more than any other generation in history,” Zaba said.

“The concept of 20/20 vision is based upon the Snellen chart, which was invented in the 1860s,” he continued, “where eyesight is based upon clearly seeing words or letters 3/8" high at a distance of 20 feet.

“Regular eye health examinations are critical, and visual acuity is important,” Zaba said. “Equally important is the visual processing of information that can be diagnosed by additional testing, including developmental visual, cognitive and sensorimotor evaluations. You have to distinguish between eyesight and the visual processing of the visual stimuli.”

A clinician must make a differential diagnosis, according to Zaba. Are the patient’s symptoms caused by errors in the visual system that are interfering with the visual processing of information, or are there other diagnoses that need to be ruled out by other practitioners? A multidisciplinary approach should be considered when a patient has problems with attention and memory.

“The visual processing of information is the total process responsible for the reception and cognition of visual stimuli,” Zaba said. “The output of this process is the visual motor response, visual auditory response and the visual vocal (speech and language) abilities. When you’re copying from the board or a textbook or even using your computer, this visual process comes into play. If these skills aren’t functioning to the highest level, a patient could have a short attention span due to the stress of the undetected nearpoint visual problems. This can result in errors in both attention and visual memory. Simply put, the wrong information is received or distorted.”

Therapeutic methods

According to Warshowsky, the methods used to treat attention and memory are varied and largely depend on the individual practitioner.

It can be as simple as therapeutically resolving refractive error with the appropriate lenses to enhance focus or it can be slightly more complex and involve following sequential lights on a board to enhance tracking and stereoscopic vision, he said.

Timing and focus

Timing mechanisms are an excellent way to improve attention spans, according to Ray Gottlieb, OD, PhD.

“I use a small trampoline,” he said in an interview with PCON. “The patients bounce up and down while spelling out a sentence by saying each letter timed with each bounce. This works a patient’s eye movement and scanning skills as well as their attention. Most people can do this task, but if someone’s had a head injury, they might have great difficulty staying with it and lose track, sometimes three or four letters into it. Their mind just wanders.”

This happens especially when they come to the end of a word, Gottlieb said, and have to bounce silently to signify the space between words. Many head injury patients have trouble making the transition between saying the last letter of a word, taking the bounce, then starting the next word.

“There’s something that confuses them in that transition,” he said. “But when they learn to master it, you see significant improvement in their attention. This can happen with older patients as well, depending on their level of cognitive strength.”

The timing of the bouncing is the key operating factor here, according to Gottlieb.

“It forces the patient to do the right thing at the right time, not just do the right thing,” he said. “It teaches a more dynamic quality of attention.”

Normally, Gottlieb uses small trampolines, but sometimes patients who are too sick or injured cannot use them. For these patients, Gottlieb has trampolines with hand rails and exercise balls that patients can sit on. Metronomes and simply clapping can be used, also.

Attention recovery skills

Another reason why the trampoline is effective, other than the timing, is the fact that the learning is expressive, Gottlieb said.

“This means patients can’t just sit there and passively listen to somebody talk or watch a movie or read without really paying attention to what they’re reading, because they have to express it,” he told PCON. “They have to perform it. The advantage of this is that if their mind wanders and they make a mistake, then they instantly become aware of it. If they’re just doing it silently to themselves, they don’t notice their mistakes, and nobody else does either.”

When a mind wanders, there are two important factors to be considered when performing this type of vision therapy, Gottlieb said. First, how quickly did the patient come back when the mind wandered? Did the patient read five more sentences before realizing he was not taking in any of the information? Second, when the patient has begun paying attention again, does he or she remember what he or she was doing before wandering?

“Recovery is what it’s called when you’re able to be so alert that when you make a mistake, you can actually catch yourself doing it, bring yourself back to attention and continue on as if you had never lost your attention,” he said. “This is a trainable behavior.”

“In terms of attention training,” Harris said in an interview with PCON, “a lot of the work we do with lenses is going to improve it. For example, we do what’s called monocular accommodative rock.”

According to Harris, monocular accommodative rock consists of having a patient read material 16 inches away, alternating with a plus lens and a minus lens. The patient will read two or three sentences with the plus lens, then switch to the minus lens for the next two or three sentences, then switch back to the plus lens.

“What they’re learning to do is to shift the accommodative mechanism from one end of the range to other end of the range. And while they’re doing that, they’re also having to read at the same time, which trains them to sustain their visual attention,” he said.

Stress point

Another important aspect of vision therapy is what Gottlieb calls the “stress point.”

“What you’re trying to do as the vision therapist is to find the task difficulty level that’s just able to cause the person to have to make a mental effort, a cognitive or attentional effort, to rise up to the level of organization in order to complete the task,” he said. “You have a particular window you have to hit. If it’s too difficult they may start to exhibit very negative learning behaviors — low confidence, withdrawal, anger.”

The stress point is a compromise between what is too easy — what will allow the mind to wander — and what is too difficult — what will discourage the patient and harm the learning process, according to Gottlieb.

“A lot of times, mental capacity is linked to confidence, which is based on success or failure,” he said. “If you design the right kind of tasks and coach in the right kind of way, then you can get people through the rough spots of whatever task you’ve given them.”

This is only possible as long as the tasks remain within the stress point window, Gottlieb said. And this success over time will make patients better able to reorganize their brain in such a way to make their attention last longer.

“This is important, because things you’ll be working on with them are everyday tasks directly applicable to quality of life,” he added.

Working memory capacity

According to Gottlieb, attention and memory are closely linked; therefore, while working with a patient on attention visual therapy, a clinician can also improve the patient’s working memory capacity.

For example, the clinician can have the patient on the trampoline count to 10 while using each bounce as a beat, he said.

“If the patient can complete this task, then have them count to 10 again, but when they get to four, tell them to bounce the four-count, instead of saying it aloud,” Gottlieb said. “If they can do that, then have them bounce the four-count and clap the seven-count instead of saying seven. Then if they can do that, have them count and instead of saying two, say their name, and so on.

“Somebody with poor working memory or short attention span is going to get so involved in the path of getting to 10 that they forget they’re not supposed to say four,” he said. “By doing this, you’re building up their ability to remember this list of things for which they have to change their mindset as a part of working memory, from one type of category to another type of category, but having to continue in a sequence at the same time.”

This expands the capacity of the patient’s working memory, which is their ability to hold in the present those parts of the past that are necessary in order to succeed at the task, or to succeed at more than one task at a time, Gottlieb said.

“It’s something that applies a lot to older people, to children with learning problems and certainly head injury patients,” he said. “This causes tremendous changes in people with head injury.”

Another method of testing working memory is what Harris called the Monroe III Visual memory test.

The Monroe III consists of asking patients to look at four symbols on a screen for 10 seconds. After the 10 seconds, the symbols disappear and then the patient is asked to draw as much as can be remembered. This is repeated three times, with a total of 16 symbols.

“This gives us a basic score and an approach, and then we would go about remediating the deficits,” Harris said. “Technically, it’s a test, but it also functions as a training tool.”

Another activity Harris might have his head trauma or pediatric patients undergo is having them make a three-block pattern and put it on a table. They look at the pattern, usually comprising a diamond, triangle and square block, then spin 180° to a table behind them, which has another board. They must try to recreate what they were just looking at.

“This helps with young children, in particular,” Harris said. “For example, say their parents tell them to go to their room and get this and that, bring those downstairs and do this with them. A lot of young kids have trouble with this. When they get better at matching the shapes of the plastic board to the shapes of what they originally saw before they spun around, they will get better at using their memory. While the directions are being given, they will start picturing where they should go and what they need to do.

“These are important underlying abilities that can change a person in the workplace – their productivity, the quality of their work – and in sports. It can be the difference between an average athlete and a superstar,” Harris said. “It can make a very big difference.”

Incorporating into primary care

Optometrists may want to consider expanding their practices into vision therapy, particularly to meet the rising demand for primary care in the U.S.

“A minimal investment in vision therapy equipment and some time spent with continuing education can serve to significantly expand a primary care practice,” Warshowsky said. “Another way of incorporating this could be by bringing into the practice an associate knowledgeable in vision therapy. Often this will be a new graduate looking to gain knowledge about private practice.

“Incorporating a vision therapy aspect into a practice will enable the practitioner to tap into a high demand market with low cost,” he said.– by Daniel R. Morgan