Vision Therapy is Messy

In his book Messy: How to be Creative and Resilient in a Tidy-Minded World, Tim Harford provides examples of how extreme organization and structure, reduced diversity, and oversimplification makes things easier but constrain and compromise outcomes.

Vision is complex and each person’s combinations of problems and circumstances is unique. Vision doesn’t function in isolation. It is represented in more areas of the brain than any other sense. It is involved in almost everything we do. How we see the world is an integral part of who we are. It follows that enhancing essential visual functions;

-eye alignment and movement,

-focusing,

-object perception, spatial perception, and guidance of movement

is messy and complex and that it is naïve to think that therapy is not influenced by the patient’s mindset, age, conflicts, and prior experiences.

All of this must be taken into consideration to treat patients. Computerized programs cannot do this but they can be useful to stimulate attention and motivation. It also requires more than a list of techniques. Doctors and therapists need to be ready and able to modify plans to match the patient’s current visual abilities. Optometric vision therapy is provided by doctors and therapists with specialty qualifications. Certified doctors are Fellows in the College of Optometrists in Vision Development (FCOVD). Certified therapists earn the title, Certified Optometric Vision Therapists (COVT). The College of Optometrists in Vision Development is the certifying body for this specialty.

Relationships between providers, patients, and their families are integral to the success of all healthcare, especially incremental care. Atul Gawande wrote about one of thirteen centers for treating patients with cystic fibrosis in the US in his book Better. One center had much better outcomes than all of the others even though the centers all followed the same protocol. The difference was that the director in one center got to know his patients personally. The better understanding and communication that resulted from these personal relationships fostered improved compliance. Atul Gawande also addresses this in his article on The Heroism of Incremental Care.

Therapy is an interplay between treatment and assessment as the patient progresses. The doctor and therapist continue to learn about patients from the way each patient responds. Dwight D. Eisenhower stated in reference to war that “Plans are useless, but planning is indispensable.” This also applies to other complex, messy situations.

Vision therapy is not easy and can be frustrating. Plasticity in Sensory Systems makes therapy possible. While neuroplasticity declines with age, it continues throughout life. Motivation can recruit surprising amounts of plasticity.  The Power of Habit balances our ability to change. Habit enables us to function without consciously thinking through everything we do, which is not possible, but it can also cause us to err when conditions change. Therapy develops new visual habits.  Focused rehearsal under a variety of circumstances facilitates supplanting existing habits with new skills and makes them more automatic than the dysfunctional patterns that they are replacing.

Optometric vision therapy takes advantage of neuroplasticity and the messiness in our visual system to make change possible. Therapy creates new visual patterns to be more efficient, more comfortable, and less taxing. Patients must achieve this for themselves, but appropriate feedback at the right time can be powerful, which is why doctors and therapists are indispensable in this process. Daniel Coyne provides example which demonstrate this in The Talent Code as does Norman Doidge in The Brain that Changes Itself. Humans are endowed with amazing abilities to learn and to adapt.

The Man He Became

How FDR Defied Polio to Win the Presidency

James Tobin

Franklin D. Roosevelt, seldom seen as a polio survivor, with Ruthie Bye and Fala, 1941

There are a few stories interwoven in this book. It starts with information about polio, immunity to polio, the change in the disease as hygiene changed, and postulates how Roosevelt contracted the disease. It also presents what may have been done, with the knowledge and techniques available at that time, which may have reduced the degree of his paralysis.

It continues with the story of his seven years of rehabilitation from the time he contracted the disease in 1921 until he was elected governor of New York in 1928.

FDR at Warm Springs; Courtesy of Vanishing Georgia

Interwoven with this is background on his goals and determination; his deep and longstanding political ambition. Tobin makes it clear that the people knew that he had polio and that he had lost the use of his legs. His rehabilitation was not a secret and he never stated that he could do anything that he couldn’t do, but the main goal of his rehabilitation was to be able to appear to not be a cripple. Cripple’s were believed to have mental limitations and certainly could not manage the demands of being President. This is a new perspective on Roosevelt and the affects that polio had on him from what has been written in the past.

Tobin also attempts to discover the source of Roosevelt’s resilience which was not expected by most of those who knew him. They saw him as a pampered. During his rehabilitation, Roosevelt spent at least as much work on developing is upper body as he did working on his legs. This was important for him to be able to transfer. It also enabled him to be able to drag himself across the floor in case of a fire. Paradoxically, the increase in the size and strength of his upper body made him appear more vital than he was before he became ill.

Day 29: FDR & Fishing
President Roosevelt was an avid, lifelong fisherman. After his mobility became limited when he contracted polio in 1921, FDR spent a great deal of his leisure time either sailing or fishing.
Dr. Ross McIntire, Roosevelt’s...

Perhaps no one can know their limits until they are challenged. Is resilience like immunity? Does it have to be challenged to develop? What can be learned from studying resilient people? It is Tobin’s conviction that Roosevelt did not overcome polio to become president. He became the man that he did because he had polio, not despite it. He was a very private person who usually had a great deal of self-control. He didn’t write diaries and he did not confide in others. It was always difficult to determine what he was thinking or feeling.

George “Dan” Draper and Roosevelt were friends from Groton and Harvard. Draper was his personal physician and believed that in many cases disease and recovery turned on forces beyond the reach of conventional medicine. Few doctors of the era believed as strongly as he did that a patient’s state of mind could tip his chances toward success or disaster. He had founded a clinic at Presbyterian Hospital for the advancement of “constitutional medicine”, a branch of the healing arts that would wane to obscurity until, decades later, it reemerged with new vigor under the name “holistic medicine”. Draper was one of its leading American advocates. He believed deeply in what a later generation would call “the mind-body connection”. He was wholly in sympathy with the scientific advances that had revolutionized medicine in the nineteenth century – germ theory, pathology, bacteriology, physiological chemistry. But he and a few like-minded colleagues were convinced that physicians of their generation – trained in the new scientific medicine, armed with microscopes, zealous to reduce disease to matters of pathogenic microbes and lesions – were losing sight of the true object of their work: the human being, in all his or her imponderable complexity.

Image result for polio in infant

            Two thoughtful students of Roosevelt’s career, Amos Kiewe and Davis W. Houck, have noted that “a physical impairment’s meaning is never fixed.” Dead cells cannot be restored to life; the physical realities of loss may be unchangeable. But the person who has suffered the loss, if allowed to do so, may determine for himself what the loss will mean. The doctors allowed Roosevelt to do that. They allowed him to shape his own story of what had happened and what was to come, a story he would tell himself and everyone else over and over.

Image result for polio fdr

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