Pencil Pushups – Valuable or Futile?

Posted on by Leave a comment

During a recent conversation, a trusted and learned optometry friend opined Pencil Pushups are a worthless activity and should be banished from the mind of everyone associated with Developmental Optometry. What’s more, continuing to administer Pencil Pushups in their traditional form would garner laughter from colleagues and outside professionals

OK, maybe my rendition of the message being conveyed is a bit dramatic, and even a touch exaggerated, but you get the idea. The strong point being made was Pencil Pushups are an antiquated concept which has been proven to be ineffective; one to which we needed to both remove from our treatment regimen and find more effective options.

This is all came to pass because I made mention that Pencil Pushups are still a tool in my toolbox, and admittedly, are included at some early juncture of a patient’s program. I may or may not ask each respective patient to perform the activity in the same manner, and perhaps not even the way the activity has been written up by many, but conceptually, the activity remains unchanged. It has always seemed to me to be a great tool for introducing concepts like feeling tone with convergence, balancing the accommodative/vergence relationship, understanding physiological diplopia, and even gaining an understanding of one’s visceral reaction as visual demands increase or visual space changes.

As many by now surely are aware, Pencil Pushups were included as part of the CITT study, which was enacted to determine whether different types of visual treatments were more effective than placebo treatments, as well as to determine if there are differences in alleviating symptoms given these different treatments. The Chairperson of the CITT Study, Developmental Optometrist, Mitch Scheiman O.D., a professor at the Pennsylvania School of Optometry, used four different groups of individuals:

  1. Scheiman M, Mitchell GL, Cotter S, et al. A randomized clinical trial of treatments for convergence insufficiency in young adults.  Opt Vis Sci 2005;82:583-595.
  2. Scheiman M, Mitchell GL, Cotter S, et al. A randomized clinical trial of treatments for convergence insufficiency in children.  Arch Ophthalmol 2005;123:14-24
  3. Convergence Insufficiency Treatment Trial Investigator Group Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. Arch Ophthalmol 2008;126: 1336-1349.
  4. Pediatric Eye Disease Investigator Group. Home-Based Therapy for Symptomatic Convergence Insufficiency in Children. Optom Vis Sci, 2016;93:1457-65

As a stand alone treatment, Pencil Pushups, were found to be ineffective.

Operative Phrase: Stand Alone

The CITT study essentially detailed the relative ineffectiveness of traditional Pencil Pushups as a stand alone iteration, and further found the activity to be no more effective than its placebo counterpart. A common misconception seems to be that these findings identified Pencil Pushups as having no value, and in turn, may be the reason some point to CITT as a basis for suggesting Pencil Pushups be removed from existence in all Vision Therapy. Although I understand how some may find these concepts interchangeable, we should be careful to delineate between the two concepts.  In a bubble, or as a stand alone take home activity, Pencil Pushups may have little to no value – a statement which could be legitimately made about most activities – but when coupled as part of a greater treatment regimen, the activity can have value and could remain in the hierarchy provided it’s supervised by an OD and/or Vision Therapist. As part of this broader treatment plan, Pencil Pushups can be an important stepping stone in building the visual skills necessary for visual efficiency.

For further clarity, I reached out to Dr. Mitch Scheiman asking for his thoughts. He graciously responded with the following:

In all four studies pencil push up therapy, as a stand-alone treatment, was no more successful than placebo treatment.

.
Of course that does not mean that pencil push-ups was never effective.  Pencil push-ups, as a stand-alone, seems to be effective in about 20-40% of subjects in our studies. The primary reason I think it has limited effect as a stand alone treatment is that is does not separate the plane of accommodation from the plane of convergence, and therefore, does not entirely work on fusional vergence. The second reason for its lack of effectiveness is that it is not an engaging procedure and most children will not practice the technique enough.
.
That does not mean, however, that we should abandon its use in an office-based program of VT.  It does have value as a means to develop the kinesthetic awareness of converging and diverging, and should be used in the early stages of VT.
.
A few other incredible sources of Vision Therapy knowledge added:
.
I think that some have misconstrued the findings of the CITT study. As a stand alone therapy, pencil pushups were as effective as the “fake” VT, but neither was as effective as the in-office treatment. That is not quite the same as saying they had no value; and in fact many studies have demonstrated the efficacy of placebo. ~ Linda Sanet
.
Taking a procedure in ‘isolation’ and determining its ‘effectiveness’ really isn’t that worthwhile. I think there are many VT procedures that if someone wasn’t really aware of the purpose or the little nuances we include during the performance of the procedure, they would think the procedures are ‘ineffective’. ~ Tom Headline
.
In conclusion, I am grateful for the CITT study and the boost it gave to Developmental Optometry. The study has truly revolutionized the world of Vision Therapy and we all owe Dr. Mitch Scheiman an incredible debt of gratitude. Moreover, it’s important to remember what the CITT study truly identified and further to understand the importance of the term ‘stand alone’. In Dr. Scheiman’s own words, abandoning Pencil Pushups is not the answer; rather, the answer is understanding how the activity fits in the broader scheme of building efficient visual skills.

Pencil Pushups can stay.

My heartfelt thanks to Dr. Mitch Scheiman, Linda Sanet COVT, Tom Headline COVT, and the many others who helped to steer this post in the right direction.

Cheers!

Discover more from VT Works

Subscribe to get the latest posts sent to your email.

Leave a Reply