VT Works

The true beauty of the Space Fixator might be in its inherent ability to connect the space we perceive with the space that is actual, no matter the disparity that may exist between our idea of what is tangible and what is actually true. It really is a pretty powerful piece of equipment.

There are no financial interests represented here, and there are many companies out there who offer their version of a Space Fixator as the best, and surely they are all good products. For my money, though, the preferred product is a sturdy setup, on a nice and clear piece of plexiglass, which takes the various heights of patients into account and can be adjusted with ease. A quick Google search of “Space Fixator” will present you with many options.

There are some instances where a Space Fixator is constructed on something solid (non-transparent); a piece of wood or a wall, for instance. While this isn’t necessarily wrong, understand it does limit the effectiveness of the activity somewhat, in that the patient will not be able to have a full appreciation of the space directly behind and beyond the dots. As we work to build Z-axis awareness and help our patients to solve the “Where Is It?” question, having the ability and awareness to map the space becomes incredibly important.

Part Two – Eyes and Hands

As mentioned when we reviewed Part One, this sequence of activities truly build on itself, so it is incredibly important that each patient not only has a good awareness of the needed skills to accomplish each level, but also achieves as close to a mastery level as they are able. That statement may be true for most activities, but especially so for Space Fixator.

Ideally, our patients are standing for level two, but again, if they have a limitation, dizziness or otherwise, seated will work. If they are able to stand, hopefully they can do so in a balanced and relaxed fashion, with the opportunity to remain aware of the space around them. To help with this awareness, it is generally a good idea to work this activity in the most open space of your VT room.

For this level, our patient should remain occluded, as part of our goal is to equalize awareness from one eye to the other. Our setup, in terms of how the patient is oriented to the Space Fixator, remains the same.

• LOOK: to begin, the patient should be fixated on the center dot while being encouraged to maintain a full peripheral awareness. For this level to be truly effective, the patient should have a general awareness of ALL the dots in the circle, while maintaining central dot fixation. Upcoming will be the instruction to use the peripheral awareness of each dot to make a smooth and efficient movement, making this an important step. When the patient is ready, they are asked if they have an awareness of a specific dot in the pattern, when they answer in the affirmative, they should be asked to “use” the peripheral information they have gathered to make an efficient movement to the dot. The Vision Therapist should watch for overshooting and/or undershooting. When the movement is complete, the patient is asked “how they did?”. If the movement is relatively efficient, the activity continues. If not, the patient can repeat this step of the activity, again being reminded to use their peripheral awareness of the location of the dot to make an efficient movement.
• READY: while maintaining fixation on the outer dot, the patient is instructed to touch their temple with the hand that corresponds to the un-occluded eye. This step seems to reinforce both the “Where Am I?” factor through tactile grounding, and begins to answer the “Where Is It?” which is always relative to the former.
• TOUCH: the next step in this process is to have the patient actually touch the dot in the outer circle they are visually fixated on. The goal of this step is to have the patient attempt to make contact with the dot gently, accurately, and near the center. In this phase, the Vision Therapist should observe the quality of the patient’s fixation, the force with which the patient contacts the dot (light touches might indicate the patient perceives the dot closer than it really is, and firm toucher might indicate they perceive the dot farther than it is), and lastly, can the patient hit the center of the dot with relative ease. Any anomalies noted could be presented with a questions, such as “how did you do?”, “were you able to keep your eye on the dot the entire time?”, “what might you change on the next dot?”.
• BACK: much like the name suggests, this is an opportunity to reset. The eye should return to the center fixation target and the hand to the patient’s side. Not to be forgotten, though, is the opportunity to ask the patient to maintain peripheral awareness during the eye movement. The instructions above (use the peripheral information to make an accurate jump) still apply, and the patient should be offered the same feedback on the return saccade.

This four step process might be done slowly at first, as the patient works their way around the circle of dots and the Vision Therapist offers feedback. In the beginning, it may work better if the Vision Therapist calls out the commands (Look, Ready, Touch, Back) which will allow the patient to concentrate fully of building their peripheral awareness.

Again, the two main keys to this activity seem to be:

• the patient’s ability to remain aware of ALL the dots on the pattern at all times
• the patient’s ability to ‘use’ their peripheral awareness to guide an efficient and accurate eye movement

Once the patient has a solid grasp on the activity, the sequence can could be repeated with the other eye occluded, and eventually done with both eyes open. Remember not to rush, though, as building peripheral awareness, and in turn central peripheral integration, is likely a top three skill in the hierarchy of mitigating a patient’s visual challenges.

As the patient practices, and both efficiency and speed increase, the Vision Therapist might consider asking the patient to call out the commands on their own. Remember, though, verbal output adds a level of integration and demand to the task.

Other challenging loads the Vision Therapist might consider as the patient improves may be the metronome. Many people have different ideas on the best speed for the metronome, but for the purposes of this write-up, let’s suggest 60bpm, which seems to align best with our Circadian Rhythm.

Alternating hands might add another challenge. This means with the right eye open, the patient performs the activity fully with their right hand, and then fully with their left hand.

The Vision Therapist may also consider adding a gravity challenge to this activity by placing the patient on a balance board, rocker board, or some other device which increases the demand on the patient’s sense of balance.

Lastly, there is the distraction factor, which some refer to as “jamming”. This is where the Vision Therapist creates a distraction in an attempt to pull the patient’s focus off the task at hand. This could be done with visual distraction, auditory distraction, or by some other creative means. So little of what most people experience in their every day lives is done in a quiet and visually pleasing place, which makes this step crucial to the patient’s ability to maintain their new skills outside the office. Make the distractions “real life” by working in a spot in the office where there is a lot of foot traffic, working in a place where the voices of co-workers or other patients can be heard in the background, or even recite your favorite recipe as the patient works on the task. All of these will increase the patient’s ability to filter out the unwanted information and maintain focus on their peripheral awareness, thereby increasing their chances of benefitting from this new found skill sooner rather than later.

Stay tuned for Part Three!