As noted previously, home vision therapy is something that is engendering alot of discussion and opinion on the vision therapy doc’s listserve.
We know that home alone therapy isn’t likely to work much better than a placebo, at least in the context of the CITT study. Yet we also know that the designers of home therapy systems put a great deal of thought and design into principles of operant conditioning, behavior modification and feedback as applied to vision therapy. Perhaps some of those ingredients can be better adapted to the current environment in which home (or any out of office) therapy is to be conducted. One approach is to consider the scientific basis for optometric vision therapy as cited by Ciuffreda (Optometry 2002) regarding the three phases of perceptual and motor skill learning:
1. Verbal-cognitive phase: This primarily involves conscious thinking and planning of movement strategies; hence, one either learns new movement patterns, or reshapes old ones, via a trial-and-error approach. Initial performance varies considerably as a range of movement strategies is attempted, with most being discarded in favor of the most-effective and efficient one.
2. Associative phase: This single, new movement pattern is practiced repeatedly and “fine tuned.” When the movement pattern is learned reasonably well, increases in task complexity and changes in prevailing conditions are instituted to ensure task success and systematic continuation of motor skill development.
3. Autonomous phase: The highly practiced movement pattern, or motor skill, has become automatic and below the level of consciousness. Motor performance is consistent, precise, efficient, “time-optimal,” and accurate. Hence, the motor pattern becomes “pre-programmed” and, in essence, “open loop” (i.e., without the need to consciously monitor its feedback). This is in contrast to the earlier two phases, in which feedback is essential and continuously monitored (i.e., closed-loop) to improve motor performance.
It would seem difficult though not impossible for the average patient to be able to accomplish these phases out of the office. In fact, one of the ploys of professionals who dispute the value of vision therapy is that patients will not comply because VT is simply too onerous.
Several years ago we had a patient in his late ’20s who became known to our therapy staff fondly as Diligent Dave. He would keep a daily diary of his home therapy experiences and email it to the staff once weekly. Here is one entry regarding the Brock String: “In the office, it seemed I had to tilt my head to the right to really get the beads in focus, with the goal of turning my head back to the left so I could maintain convergence while having a fairly straight ahead position. However at home I found myself not having to tilt my head right or left, but rather up and down. It was much easier to keep the beads in focus when I looked slightly downward at them.”
The bottom line is that the out of office therapy experience can vary quite a bit depending on the individual patient. An adult patient may wish to spend considerable time on just a few key procedures which she finds most beneficial. A child may require the supervision of an adult in order to gain anything meaningful out of home therapy. Home VT should not be a “battle”, nor she it be so simplistic that it doesn’t aid transfer to activities of daily living.
For the therapy to be meaningful, it should be internalized, it should help to orient the individual, and its benefits should be evident to those with whom the patient communicates.