“I went to the eye doctor and they said my eyes were fine.” As the saying goes, If I had a nickel for every time I heard this. I do hear this a lot, almost weekly, while doing concussion rehab in my practice. So when the patient says my insurance company will only allow vision exams by such and such a doctor, I warn them of this potential outcome before they even go. Yet after the exam, I continue to hear in the clinic, “My vision is blurry; I get a headache from the screen; I can only read for 5 minutes before I get nauseous or a headache”. So now what?!
As an OT, my main concern is that these people can’t function because of their symptoms or perform their occupational roles- student, worker, driver, athlete, child, or mother. Over the years, I also got frustrated for these patients who kept getting steered in the wrong direction, so I sought out courses that were taught specifically by eye care specialists and even went back for my clinical doctorate, specializing in vision remediation. This is what I learned:
OT’s are the experts in activity and occupational performance:
Occupational therapy distinguishes itself from any other field by analyzing occupations and activities. We look at the person, the occupation, the environment and the performance in order for our clients to be independent. When a child can’t play, we assess why not and address it. When an adult can’t work, we assess why not and address it. We look at the skills needed for that task and compensate for, adapt or restore that missing piece. That is what we do and we are good at it!
Many times, the performance skill that is lacking or impaired is related to vision. Adult patients may say, “I get pressure in my temples when I read or think too hard”. With children, they may not be able to verbalize a headache during play, but they may bring an object closer or farther or maybe even not attend to the object at all. This behavior can also indicate a vision problem.
Occupational therapists are fortunate because physicians refer to us when there is a problem with activities of daily living, play and fine motor or returning to learn. We are the client’s first line of defense when they can no longer participate in life. That being said, we need to acknowledge that there may be a visual inefficiency causing their problem based on what is seen in our sessions and reported by family feedback. We need to be the referral source to eye care specialists for these patients that we see weekly, BUT we must know who to refer to.
OD’s are the experts in vision:
To differentiate, an ophthalmologist is a Medical Doctor that specializes in eye care, including the diagnosis, management, and surgery of ocular diseases and disorders (American Academy of Ophthalmology, 2018). The main emphasis is on surgery and prescribing medications for eye disease. However, they spend limited time in their education on the areas of visual efficiency and visual information processing and focus on a single component model of vision that only incorporates the category of visual integrity problems.
Optometrists are trained to use the 3-component model of visual integrity, efficiency and information processing (Ciuffreda, Ludlam & Yadav, 2015; Scheiman, 2011). They have a more complete understanding of the use of lenses, prisms, and vision rehabilitation to remediate ocular function, in turn, improving visual and occupational performance. It is important to note that while all optometrists receive this training, only a small percentage practice in this way.
I equate these two professions’ relationship to the OT and PT relationship. Let’s take an orthopedic condition, like a hip fracture. A physical therapist may look at the structure of the hip, including the strength and ROM of the hip, pelvis, and back so that the person can get back to walking. They may issue a cane or a walker so that they can move around. Occupational therapists, in turn, will look at the function of the entire person- can they dress themselves with or without adaptive equipment, can they get to the bathroom, can they stand and cook a meal, can they perform leisure pursuits?
The same is true for these two eye care professions. Ophthalmologists will look at the structure of the eye including the retina, the optic nerve, while checking for such things as glaucoma or cataracts. They may issue glasses so that the client can see. Optometrists, in turn, will look at the function of the eye- are the eyes converging and working together, are they communicating to the brain to perceive their environment appropriately, are they getting headaches after reading for 5 minutes due to an eye inefficiency? Each profession has a role in serving the client, but they are also specific, resulting in different treatment.
In terms of concussion rehabilitation or pediatric therapy, occupational therapists should be referring to those who perform a comprehensive eye exam and acknowledge the dysfunction occupational therapists see during treatment. This means referrals should be made to optometrists; but even within optometry, there is a lack of consensus and uniformity in the way eye examinations are performed. The eye-care professional that occupational therapists chose to refer to should perform the examination using a 3-component model of vision that includes the categories of visual integrity, visual efficiency and visual perceptual deficits that can impact occupational performance.
Visual integrity includes the areas of visual acuity, refraction (optics of the eye), and eye health. This area is always examined by both optometrists and ophthalmologists. The visual efficiency category includes accommodation, binocular vision, and eye movements, while visual information processing includes visual spatial, visual analysis and visual motor integration skills (Scheiman, 2011). Whether an eye examination includes all three of these components or just an assessment of visual integrity plays a major role in determining the outcome of the examination and, subsequently, the care provided to the client.
These two organizations are a great starting place to find a local expert:
The Neuro-Optometric Rehabilitation Association, International (NORA) is an inter-disciplinary group of professionals dedicated to providing patients who have physical or cognitive disabilities as a result of an acquired brain injury with a complete ocular health evaluation and optimum visual rehabilitation education and services to improve their quality of life.
The College of Optometrists in Vision Development (COVD) is a non-profit, international membership association of eye care professionals including optometrists, optometry students, and vision therapists. Established in 1971, COVD provides board certification for optometrists and vision therapists who are prepared to offer state-of-the-art services in: Behavioral and developmental vision care, Vision therapy and Neuro-optometric rehabilitation.
These specialized vision care services develop and enhance visual abilities and correct many vision problems in infants, children, and adults. Vision care provided by all COVD members is based on the principle that vision can be developed and changed.
A collaborative effort means the client wins
So what does this relationship look like? It has the potential to take many forms. Ideally, it may look like this:
The fields of optometry and occupational therapy are truly kindred spirits. Both professions look at function when serving clients. Both are experts in their own right, but share the ultimate goal of improved occupational performance, symptom free. Both need each other’s expertise to achieve that goal. And ultimately who wins? The client.
American Academy of Ophthalmology. (2018). The eye care team. Retrieved from: https://www.aao.org/about/eye-care-team
American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68 (Suppl 1), S1-S48. doi: 10.5014/ajot.2014.682006
American Occupational Therapy Association. (2014). Scope of practice. American Journal of Occupational Therapy, 68 (Suppl 3), S34-S40. doi: 10.5014/ajot.2014.686S04
Ciuffreda, K. J., Ludlam, D. P., & Yadav, N. K. (2015). Conceptual model pyramid of optometric care in mild traumatic brain injury (mTBI): A perspective. Vision Development and Rehabilitation, 2, 105-108.
Scheiman, M. (2011). Understanding and managing vision deficits: A guide for occupational therapists (3rd ed.). Thorofare NJ: Slack, Inc.
A new year brings new experiences, new activities, and you guessed it, NEW OCCUPATIONS. That goes for me as well. I truly believe that education and program development are the cornerstones of giving good care to those we serve. Everyday is a new opportunity to rethink out of the box and resolve ourselves to improving our skill set. This year I am fortunate enough to be able to offer that education to our state professional organization (POTA) members regarding vision dysfunction's impact on occupational performance. I hope this forum will provide an arena for discussion and education for others, as well as myself, in order to move our profession forward and continue my own growth and understanding.
I am posting this blog here as well because it is important to know who is treating you, what's the backstory, and....what is she up to now?
...We wanted to start the group off by introducing ourselves and giving you a brief history of why we asked for this network to be initiated within the Commission on Practice sector of POTA.
I have been an occupational therapist for 18 years and, in that time, have worked primarily with adults and geriatrics in various settings. My love revolves around neuro rehab, including strokes, MS, Parkinson’s and most recently concussions. As concussion rehab has come to the forefront over the last several years, my interest became locked in on visual dysfunctions and symptoms that were common place for those who sustained a concussion.
In 2013, I took my first vision continuing ed course, “From Eyesight to Insight”, co-taught by Mary Kawar, OTR, of astronaut training fame, and Carl Hillier, OD, FCOVD, creator of the multimatrix game. It was geared towards pediatric therapists but I thought that it could definitely apply to adult neurological rehab as well, so I took a chance and took the course. Little did I know at the time how influential these two would be on my understanding of visual screening going forward.
I took their information and started to apply it to my practice. So now I had this awesome toolkit on how to screen for visual dysfunction, but no one to refer to. Within our network there was no one who acknowledged the need for vision remediation and the closest optometrist who did was 50 minutes away in another state. I tried to work with an ophthalmologist 2 blocks away who said to me upon meeting, “You don’t believe in that vision therapy stuff do you?”, and handed me the American Academy of Ophthalmology’s position statement from 1999 that stated there was no research and it didn’t work. This was 2014. I was so frustrated having identified a huge area of dysfunction that no one was addressing, and I, as an OT, couldn’t address, as prisms and lenses were out of my scope of practice to assist with blurred and double vision.
Fast forward to 2016. My supervisor, knowing I had an interest in vision, sent me a link to another pediatric course, taught by Mitch Scheiman, OD, PhD, FCOVD. It was here that I learned of the new clinical OTD that was being offered at Salus University. My mother, Maxine, had just passed away 6 weeks prior to this course, my dad was most likely going to be moving in with us from CT…how on earth could I even entertain getting my doctorate just because I liked vision and identified its impact on occupational performance? At the end of the day, Dr. Scheiman mentioned a story about his wife, who was an OT…. her name? Maxine. I took it as a sign to follow my instinct and sign up. After 16 years of practice, I was back in school and learning from the best. I was honored to have the support of Dr. Scheiman as my mentor, who has over 200 published articles regarding vision dysfunction and remediation.
After explaining my frustrations to him both from an OT standpoint with every therapist having a different understanding of skills and role, and frustrated with the eye-care profession after hearing for the millionth time, “Their eye health is fine”, I developed my capstone. It was a survey that I created, sent to therapists in the most densely populated OT licensed states, regarding “Concussion-related vision disorder practice patterns in occupational therapy”. Questions revolved around screening technique knowledge, treatment practice patterns, referral patterns, certifications and continuing ed, scope of practice beliefs, frames of references and what, in fact, is OT's role, if any. And the results that I got were proof positive that something needed to be done!
Data from this study suggested the need for the following changes in occupational therapy practice:
Having presented my poster this past Fall at the American Academy of Optometry in San Antonio, and being accepted to present this April at AOTA in New Orleans, I know that my research is important not only to me, but at least two other professions. I look forward to providing you with evidence-based practice and information that will help you help your patients when they demonstrate dysfunction with visual acuity, visual efficiency and visual perceptual skills. Let’s move the profession forward. Cheers!
It's that time of year again when we all look at our lives and determine what it is we want to improve upon. Ok, let's be honest. Resolutions typically revolve around what we don't like about ourselves.... our diet, our temperament, our lack of exercise or not being the best person we know we can be. I know mine usually do. And by the end of January, if I'm lucky, they have fallen by the wayside and put back on the list for next year.
So why aren't we successful in keeping these promises to ourselves, the most important person in our lives? While reflecting on why mine usually fail, I had a revelation. Resolutions are synonymous with occupations and life roles and routines. Funny, as it's the basis of the field of occupational therapy and here I am, failing at it every year! So what if for 2019 I pick an occupation I want to work on and start to adapt that to how I want it to look?
Occupations are everything we do in a day... eating, exercising, working, seeking out leisure like crafts, woodworking, gardening. Hey look, resolution material! Here's what I'm thinking: for example, let's look at the resolution of improving diet and nutrition. To achieve this resolution, we need to create healthier meals, whatever that looks like (sugar detox, keto, paid for diet plans). This goal involves making menus for the week, grocery shopping, meal preparation and clean up, as well as hydration and exercise. That in and of itself seems daunting regarding changing routines in ALL of those areas. No wonder I have failed. For each one of those tasks it takes 21 days to create a habit or routine!
That's where the OT in me had an ah-ha moment, maybe long over due. What if I break down the overall occupation of maintaining a healthy diet (dream) into each component activity (goal) so that I can succeed in little steps, one task at a time each month (plan)? Maybe in January I could focus on buying more fruits and veggies (action), cutting them up for the week and making sure that I eat them everyday for lunch instead of throwing them out in a week because I forgot about them. In February I could focus on drinking more water and eating a healthy breakfast BEFORE work, in addition to my January achievements of fruits and veggies for lunch. March could bring a week at a time of meal planning, with grocery shopping on certain days making a concrete routine and habit within my role as wife and mother. All of a sudden, I have made diet changes to 3 meals a day over a period of time. Now, this resolution of improving diet and nutrition doesn't seem as daunting compared to my usual "January 1st all this must change or bust". It is truly looking more like a life change. And this life change can be my new reality. How simple to use this new perspective...and why did it take me so long to realize this step by step approach when it's what I preach everyday?!
And so to you I say, Happy 2019 a few days early. Let us all start January with a simple occupation that you want to change. Break it down into smaller pieces and spread it out over time to make it more routine, rather than jumping in gang busters. You may be surprised if by June you are still hanging onto your "resolution" and creating a new reality that's all about YOU! CHEERS!
I'll keep you posted on mine.