JB is a 12 year-old girl who began vision therapy with us recently due to difficulties she was having with double vision and headaches. She had non-comitant strabismus with habitual, mild head tilt and face turn to the left, and a “V” pattern exotropia. She was able to maintain single vision in her habitual head/neck posture, and the only remedy offered to her to date was strabismus surgery. Her mother was looking for a non-surgical approach, and I told her that while I wasn’t opposed to surgery, we would see how far vision therapy could take her in spreading her fields of comitance and single vision.
We made good progress using prisms and a variety of optometric vision therapy procedures including vertical and horizontal vergence ranges with random dot stereogram targets. Headaches were noticeably decreasing within two months and double vision lessening, but at our second progress evaluation JB’s mom mentioned that her pediatrician wanted her to try a second round of physical therapy for her scoliosis. JB felt that the six months’ she spent in PT last year didn’t have any impact on her function or headaches, and her mother agreed. She felt it was probably more the negative office environment than the PT itself, and was interested in trying a different approach. Mom then asked for my recommendation.
I recalled that one of the participants at one of my vision seminars was a craniosacral therapist who claimed to have success with cases that seemed very much like what JB was experiencing. JB’s mother was very interested in pursuing this. In a quick perusal of the literature, there seems to be only one article that directly linked scoliosis with strabismus – published in the journal Spine in 2001, though that was in a visually impaired population. I found in various sources the natural chicken vs. egg question as to whether scoliosis is the primary problem resulting in postural skews that induce paretic strabismus, or vice-versa. This is the similar chicken vs. egg questions posed in primary vs. secondary torticollis, adaptive head postures, and paretic strabismus.
Our VisionHelp colleagues Drs. Carl Hillier and Bob Sanet have long extolled the applications of craniosacral therapy as practiced by the osteopathic physician, Dr. Viola Frymann. An article in the Journal of Behavioral Optometry in 1999 by Kenneth Fry, P.T., addressed craniosacral therapy and the visual system. I located several PTs who were schooled in the Upledger technique, and gave their names to JB’s mom.
We will continue to work with JB, expanding cyclofusional ranges and integrating that in head-to-toe fashion, but remain open-minded toward the possibilities of both craniosacral therapy and strabismus surgery aiding in the best outcome and long-term stability.
A nice and important illustration of the possible intersection between optometry and osteopathy. Co-management with head injury as well musculoskeletal issues affecting the integration of vision with the body are two examples. While Upledger trained professionals can offer help, why not see a DO who generally has a much greater depth and breadth of medicine, anatomy and approaches to treatment? A listing of Osteopaths who practice this modality can be found at http://www.cranialacademy.org/index.html
Excellent point, Barry. The reason I leaned toward a PT certified in CST/Upledger is that mother was more comfortable with this approach since it aligned with her pediatrician’s encouragement to re-visit PT. But a DO is an excellent choice, as I noted regarding the collaboration between Drs. Sanet and Hillier with Viola Frymann, D.O.
I am recently diagnosed with troclear palsy, and only a year or so ago with Scheurmann’s kyphosis. I have been seeing a craniopath (a DC who basically eschews typical chiropractic treatment and theory and instead is practicing cranio-sacral modalities) and he indeed both detected a significant malformation/discrepancy in my cranial alignment (by a 1/2″!) and through another modality detected the major affect of the strabismus he was not trained to further evaluate. (And, he himself is pro-strabismus surgery, and presented a young child of his own for successful surgery.)
I would say my work with him, plus the work I did for a decade with visual therapy with Baxstrom, OD, kept me from ever considering a differential diagnosis, yes.
Certainly if my visual symptoms had gone unaddressed much longer, the palsy might have been identified earlier. I displayed at least depth perception issues as a child as well as head tilt, and had nagging symptoms of the distortions of scoliosis and kyphosis throughout childhood: again, not marked enough to ever be appropriately addressed.
It’s disappointing to realize that opportunities were lost, and potentially damage done: I am a high myope with recent IOL replacements for posterior subcapsular cataract. I do wonder if compensation for poor teaming led to continued strain and distortion, then finally inability to compensate –> pain/headache and frank diplopia. I do know my world got smaller: my first grade report card states ‘needs work with ball skills’ — realms of experiences simply were not available to me, and no one further questioned this during my development.
Meanwhile, the PT who indeed identified my kyphosis and directed me to radiographic study informed me at my first session I need to behave as if my back is fused. Another disappointment, realizing observational capacity simply was not availed by any of the clinicians seeing me as a younger person, despite complaints.
I look forward to the nexus between visual and skeletal development becoming better raised to the attention of clinicians.