In the prior blog I noted that “home therapy” is a bit of misnomer. After all, the procedures we prescribe to be done out of the office are increasingly done at places other than home. In some instances they are reinforced by professionals in school, such as OTs, PTs, or SLPs. In other instances, particularly when a parent home schools a child, it is entirely appropriate to consider some of the procedures as home therapy. The bottom line is that when we assign these procedures, it is vital to have the therapist ask the patient to demonstrate their ability with the activity or activities when they return to the office. That way we can gauge how appropriately and how well the procedure has been internalized and applied. It’s amazing sometimes to see what the patient’s interpretation of the procedure should be done, despite what we thought were clear-cut written directions, and despite having had the patient demonstrate the procedure before they left the office.
Early in my career I recall chatting with Baxter Swartwout about his philosophy regarding out of office therapy. Dr. Swartwout encouraged parents to sit in for office therapy sessions, and they became integral partners in doing therapy at home with the child. His approach and written procedures are still available in this manual through OEPF. Many of our traditional low tech home therapy activities are still uniquely good, from Hart Charts to phonetic focus to loose lens rock to peripheral awareness charts to Brock String and so on. Beyond this the home computerized therapy procedures as distributed by Home Therapy Systems, Bernell, OEPF, and Taylor Associates are uniquely suited to amblyopia, strabismus, perception, and reading. Some of our colleagues have structured home vision therapy in exquisitely detailed fashion.
The issue about home therapy often seems to revolve around compliance. I’m not a big fan of the term, but for want of a better phrase it can be challenging to keep the patient engaged in the assigned activity. While one factor can be tedium or boredom, another is that we may be asking the patient to do something they don’t do well and they will deal with it through avoidance. Not everyone buys into the “no pain no gain” motivational speeches, and our younger patients lack the maturity to persevere. Not to mention the fact that households are a bit different than when Dr. Swartwout was in his prime (or me, for that matter!). For some, even wearing the lenses prescribed consistently is a challenge, or to keep the eyewear positioned properly on their face is a victory.
I like the IT cloud model above as a metaphor for out of office therapy. There are some procedures that are specific applications, relying on proprietary software content. They require a process in which the patient is instructed on use, and availability of specific hardware or tools is required for practice. Change is relatively self-evident in terms of levels of improvement in performance over repeated trials. Retention of skills occurs through muscle motor memory of sorts for some activities, and a form of perceptual learning for other procedures.
A somewhat different approach is taken when the patient is guided on a concept, and the procedure is presented as a tool to learn the concept. Take peripheral awareness as an example. The particular chart on which we train the patient, or the light board or touch screen on which the patient practices central fixation with peripheral identification is introduced to gain the feeling of what it is like to divide one’s attention and awareness between center and periphery. The goal is not to master specific tasks. Regarding availability and access, out of office therapy occurs in any place and at any time. Change and retention is associated with the patient placing herself in a position at home, in school, in the mall, or on the road, consciously challenging herself to maintain central gaze on whatever field is ahead while simultaneously monitoring what is occurring peripherally. This conscious awareness is then confirmed by a glance. The patient must subsequently return to the office and demonstrate mastery of this skill set in similar but not identical conditions arranged by the therapist.