The Effect of Interactive Metronome Training on Children with ADHD  American Journal of Occupational Therapy (March/April, 2001, Vol 55, No 2)
     In the double blind IM Training 'effect' study, boys with ADHD, who received the Interactive Metronome intervention, were compared with a control group receiving no intervention, and a second control group receiving a placebo computer based intervention. The Interactive Metronome intervention group showed statistically significant improvements over both control groups in areas of attention, motor control, language processing, and reading, and in their ability to regulate aggression.

 New Fundamental Planning & Sequencing Timing Deficiency Patterns  Interdisciplinary Council on Developmental and Learning Disorders Conference (Nov, 1999)
    The identification of New Fundamental Planning & Sequencing Timing Deficiency Patterns in children with learning and developmental disorders was announced November 12, 1999 by James Cassily at the Interdisciplinary Council on Developmental & Learning Disorders Third Annual International Scientific Conference held in Washington, D.C..

Interactive Metronome: Effect on Motor Control, Concentration, Control of Aggression, and Learning in Children with Attention Deficit Hyperactivity Disorder   Motor Control II International Conference, Penn State University (Aug, 1999)
    Double blind clinical ADHD Study paper submitted for publication. The IM group also achieved full significance over the placebo control group. The placebo video group's significance findings support the 1998 National Institute of Health's 1998 ADHD Consensus conclusion that studies on interventions must properly control for the positive overall effect that attentive adult interaction is likely to have on the results. Significant differences were found on 11 factors (p values ranging from 0.020 to 0.000) on improving their performance in areas of attention, motor control, language processing, reading, and parental reports of improvements in regulation of aggressive behavior.

Improving Special Education Student Motor Integration by Use of an Interactive Metronome  American Educational Research Association Conference (March, 1997 )  
    The first controlled study of the Interactive Metronome system demonstrated its effectiveness in improving fine and visual motor coordination of special education students. Parent post study observations of improvements in cognitive and behavioral areas led to more comprehensive IM studies to also document the IM 'effect' in these areas.

High/Scope Study (Assessment/ Achievement Correlations)
    585 students aged four to eleven in an Effingham, IL school district were part of a study to assess the reliability and validity of the IM as a measure of motor timing and planning capacity. The results published by the High/Scope Foundation, a prestigious non-profit educational research institution since 1970, showed significant correlations between IM performance and factors of age, motor coordination, attention, academic achievement, and other areas.

J Child Psychol Psychiatry 1998 Sep;39(6):829-40 (Wilson PH, McKenzie BE)
"Information processing deficits associated with developmental coordination disorder: a meta-analysis of research findings."
    A meta-analysis was conducted to identify information processing factors that characterize children with Developmental Coordination Disorder (DCD). A total of 50 studies yielded 374 effect sizes based on 983 DCD and 987 control children. A mild generalized performance deficit was indicated, since motor-impaired children were inferior on almost all measures of information processing. There were, however, several areas where their deficiencies were more pronounced. The greatest deficiency was in visual-spatial processing. This was evident regardless of whether or not the tasks involved a motor component. Most other deficiencies were in the small-to-moderate range and included kinesthetic and cross-modal processing. The findings support the notion that perceptual problems, particularly in the visual modality, are associated with difficulties in motor coordination. 

Folia Phoniatr Logop 1998;50(3):107-17 (Gillberg C)
"Hyperactivity, inattention and motor control problems: prevalence, comorbidity and background factors."
    This paper provides a brief review of syndromes associated with activity dysregulation, inattention and motor control problems, usually referred to as attention-deficit/hyperactivity disorder, developmental coordination disorder and deficits in attention, motor control and perception. Several percent of school age children are affected by such problems. Disorders tend to overlap and show significant comorbidities. Familial and brain-damaging factors are involved in the pathogenesis and appear to impinge on specific attentional brain systems. Outcome is variable but restricted if appropriate diagnosis/intervention is not accomplished. Effective interventions are available. Given the high prevalence of these disorders and their relatively poor outcome, such interventions could constitute effective prevention in a general population health perspective.

Dev Med Child Neurol 1998 Dec;40(12):796-804 (Kadesjo B, Gillberg C)
"Attention deficits and clumsiness in Swedish 7-year-old children."
    A population study of 409 seven-year-old children in a middle-sized Swedish town was performed. All children were examined by the same doctor and evaluated by means of parent interview, motor examinations, and teacher reports on behavior in the classroom. Follow-up was carried out 8 months later. The rate of severe problems in the fields of attention deficit-hyperactivity disorder (ADHD), developmental coordination disorder (DCD), and deficits in attention, motor control, and perception (DAMP) (the combination of ADHD and DCD) was 6.1%, with boys being affected more frequently than girls. There was considerable overlap between ADHD and DCD, with about half of each diagnostic group also meeting criteria for the other diagnosis. Attention deficits at diagnosis strongly predicted attention deficits at follow-up. If parents had noted attention deficits in the home setting, then teachers almost always independently agreed that there were similar problems in the classroom. However, the reverse did not always apply. Clumsiness also showed striking stability over time. The diagnosis of DAMP, particularly severe DAMP, had a stronger association with classroom dysfunction and with high Conners scores than did diagnoses of ADHD or DCD. It is concluded that DAMP may be a clinically valid diagnostic construct.

Motor Control 1998 Jan;2(1):61-80  (Elliott D, Ricker KL, Lyons J)
"The control of sequential goal-directed movement: learning to use feedback or central planning?"
    Fifteen participants practiced a two-target sequential aiming movement with either full vision of the movement environment, vision during flight, or vision while in contact with the first target. After 100 acquisition trials, participants performed a retention test in their own condition and then were transferred to each of the other two vision conditions. Both performance and kinematic data indicated that rather than becoming less dependent on visual information with practice, subjects learned to adjust their movement trajectories to use the visual information available in their particular vision condition. Although transfer to a degraded vision condition disrupted performance, when vision was augmented participants quickly adjusted their aiming trajectories to use the added information. The findings suggest that at least part of learning involves the development of rapid and efficient procedures for processing afferent information, including visual response-produced feedback.

Scand J Rehabil Med 1998 Jun;30(2):101-6 (Sigmundsson H, Pedersen AV)
"We can cure your child's clumsiness! A review of intervention methods."
    Intervention procedures for treatment of clumsiness have come in many guises. We have looked at some of the most powerful methods put forward in the past 30 years--Perceptual-motor training (PMT), Sensory Integration Therapy (SIT), and some promising new approaches. Both the PMT and the SIT have been heavily criticized.  It is hard to find support for the idea that the programs improve academic skills or that they have more than a limited effect on perceptual-motor development as claimed.  The more recently introduced kinesthetic training is shown to have an effect on general motor competence but that this may be better explained in terms of the general principles on which this training procedure lies rather than the influence on kinaesthesis per se.  Since other recent studies have also shown a dependence on similar general principles, it might be asked whether it is the teacher rather than the programs that accounts for the differences shown between different intervention programs.

Dev Med Child Neurol 1998 Oct;40(10):672-81 (Smyth MM, Mason UC)
"Use of proprioception in normal and clumsy children."
    This study investigates the relation between performance on simple tasks dependent on proprioception, and performance of complex perceptual-motor skills in clumsy children and age-matched control children. One hundred and forty-six right-handed children aged between 5 and 8 years were tested on non-visual aiming, non-visual posture matching, the Kinaesthetic Sensitivity Test (KST), and the Movement Assessment Battery for Children (ABC). Half of the children had scores below the 15th percentile on the Movement ABC and were classed into the developmental coordination disorder (clumsiness) group. Scores on the proprioceptive tasks were used to predict performance on complex tasks of the subscales of the Movement ABC (manual dexterity, ball skills, and balance). Specific relations were found between the proprioceptive tasks and the subscales of the Movement ABC, but the KST did not predict differences in motor skills, and no relation was found between tasks carried out without vision. Simple non-visual movement tasks do predict performance in more complex skilled tasks but this is affected by many task features rather than simply the reliance on proprioception for information about movement.

Vision Res 1998 Jun;38(12):1817-26 (Langaas T, Mon-Williams M, Wann JP)
"Eye movements, prematurity and developmental co-ordination disorder."
    Horizontal pursuit eye movements were investigated in two separate groups of children: One group exhibited developmental co-ordination disorder (n = 8) whilst another group of children were born prematurely (n = 8). Both studies found a reduced gain in pursuit eye movements when the respective populations were compared with control groups (n = 32). A difference was also found in the ability of some children to temporally synchronize their tracking response to the stimulus, which was indicative of poor predictive control rather than lags in the control system. We suggest that horizontal eye movements may be a sensitive indicator of more general motor deficits during childhood development.

Rev Neurol 1998 Aug;27(156):280-5 (Campos-Castello J)
"Neurological assessment of learning disorders."
    INTRODUCTION: The neurological concept of learning is approached from a cybernetic point of view, taking into account that a child should recognize a fact, learn it semantically and decided whether it is worth storing; the dynamic aspect of memory is the true motor of the ability to learn and all this is modulated by the attention factor.
    DEVELOPMENT: The neurological evaluation of learning disorders is based on clinical examination which includes the so-called minor signs of the noetic functions, specifically language, the praxes, gnosias, perceptive-motor function, laterality and the lexical, graphic and calculation functions together with the modulating element, mentioned above, of the level of attention with or without hyperactivity. These semiological elements are grouped into three major categories of syndromes: motor syndrome, dyslexic-dysgraphic-dyscalculation syndrome and the hyperkinetic syndrome or attention deficit with hyperactivity. We also note the differential diagnosis. We review the neurophysiological biological markers (EEG and brain mapping, cerebral evoked potentials, neurometry) and those based on neuroimaging techniques (cerebral CT, MR, SPECT and PET).
    CONCLUSIONS: The contribution of neurological assessment is considered as part of the functions of a multi-disciplinary team which should deal with the diagnosis and treatment of children with learning disorders.

Dev Med Child Neurol 1998 Jun;40(6):388-95 (Hill EL)
"A dyspraxic deficit in specific language impairment and developmental coordination disorder? Evidence from hand and arm movements."
    The extent to which children with either specific language impairment (SLI) or developmental coordination    disorder (DCD) could be considered dyspraxic was examined using three tasks involving either familiar, or unfamiliar actions. SLI is diagnosed in children who fail to develop language in the normal fashion for no apparent reason, while the DCD diagnosis is applied to a child who experiences problems with movement in the absence of other difficulties. Seventy-two children aged between 5 and 13 years participated, falling into one of four groups: (1) children with specific language impairment (SLI), (2) children with developmental coordination disorder (DCD), (3) age-matched control children, and (4) younger control children. The performance of the clinical groups resembled that of younger normally developing children. Children with SLI, DCD, and the younger controls showed significant difficulty on the task requiring the production of familiar, but not unfamiliar postures. The deficit observed in the SLI group is particularly striking because it was seen both in those with and those without recognized motor difficulties.

Motor Control 1998 Apr;2(2):114-24 (Raynor AJ)
"Fractioned reflex and reaction time in children with developmental coordination disorder."
    The patellar tendon reflex (PTR) and simple visual reaction time (RT) were fractionated and compared in 40 subjects with developmental coordination disorder (DCD) and normal coordination (NC) in two age groups. Four equal groups of subjects, 6 years DCD (6DCD), 6 years NC (6NC), 9 years DCD (9DCD), and 9 years NC (9NC) were compared using ANOVA for the main effects of coordination and age. PTR and its components of reflex latency and motor time were not significantly affected by the level of coordination; however, a significant coordination by age interaction (p < .05) revealed an increased motor time in the 6DCD group. RT, premotor time, and motor time were all significantly (p < .05) increased in children with DCD; the increased RT and premotor time support earlier findings, whereas the increased motor time has not previously been found. These findings suggest that the processing of reflexive and volitional responses by children with DCD differs from that of their NC peers.

Motor Control 1998 Jan;2(1):34-60 (Volman MJ, Geuze RH)
"Stability of rhythmic finger movement in children with a developmental coordination disorder."
    The stability of single and bimanual (i.e., in-phase and antiphase) rhythmic finger movements was studied in 24 children with a developmental coordination disorder (DCD) and 24 matched controls from a dynamic pattern perspective. Stability was assessed by applying perturbations and measuring the time the system needed to return to its initial stability (i.e., the relaxation time). In addition, fluctuations of the patterns were measured. For antiphase coordination patterns, the frequency at which loss of stability occurred was also determined. Children with DCD displayed less stable single and bimanual rhythmic coordination patterns than control children. Further, within the DCD group, 9 children were identified as having particularly poor bimanual coordination stability. Individual differences suggested that variability of individual limb oscillations might have contributed to this poorer interlimb coordination stability. Findings were discussed in relation to a previous study on DCD in which the Wing-Kristofferson timekeeper model was applied.

Percept Mot Skills 1998 Jun;86(3 Pt 1):771-86 (Kioumourtzoglou E, Derri V)
"Cognitive, perceptual, and motor abilities in skilled basketball performance."
    The differences among athletes of differing skill should assist successful identification and selection of the best athletes in a specific sport. For the purpose of this study, a laboratory study was conducted with a group of 13 men on the elite male national team of basketball players, 22 to 23 years of age, and a control group of 15 men of equal age (physical education class) to assess differences in their scores on cognitive skills (memory-retention, memory-grouping analytic ability), perceptual skills (speed of perception, prediction, selective attention, response selection), and motor skills (dynamic balance, whole body coordination, wrist-finger dexterity, rhythmic ability). Analysis showed that elite male basketball players scored higher on hand coordination and lower on dynamic balance given their anthropometric measurements. Elite players were better on memory-retention, selective attention, and on prediction measures than the control group. The above skills are important in basketball performance. Researchers may examine whether other factors contribute more in the development of perceptual and cognitive skills.

Child Care Health Dev 1998 May;24(3):195-205 (Ko ML, McConachie H, Jolleff N)
"Outcome of recommendations for augmentative communication in children."
    Some children with severe motor disorders have unintelligible speech, and may be recommended augmentative communication systems, such as a symbol chart or a voice output aid. The paper reports the outcome after 15-18 months for 35 children of recommendations for augmentative communication. Using structured questionnaires, parents were asked whether equipment was provided as recommended. Their perception of success in children's use of augmentative aids was recorded and related to potentially influential factors. Twenty-five symbol systems, 10 speech output devices and 11 switches were received; 18 symbol systems were used for communication and 10 were used frequently. Seven speech output devices were used for communication but only two were reported to be used frequently. Factors leading to more successful outcomes include early receipt of the aid, perceived adequate local training in the use of the aid, and children aged 6 years or more at initial assessment. The findings also suggest that referring professionals will need to be better informed about the nature and limitations of augmentative communication aids, and that improved local professional input and careful interagency planning and co-ordination are required to achieve optimal outcome.

Dev Med Child Neurol 1998 Feb;40(2):108-14 (Steenbergen B, Hulstijn W, Lemmens IH)
"The timing of prehensile movements in subjects with cerebral palsy."
    In this study, a paradigm is presented for the assessment of manual dexterity in subjects with cerebral palsy (CP) that divides the prehensile action into a 'time-to-contact' phase and a 'time-in-contact' phase. Two experiments were performed that determined the effect of object weight on the timing of both phases for the impaired hand and non-impaired hand of subjects with spastic hemiparesis (N = 14). In the first experiment, subjects had to reach for and lift a tube at their own preferred speed. The results showed that the prehensile deficit of the impaired limb is to a large degree manifested by a longer time spent in contact with the object before it was lifted. The time-in-contact phase was decreased after repeated lifts, suggesting that subjects with CP can control and modify force output in advance based on weight information from preceding lifts. In the second experiment speed of movement execution was stressed to examine whether the observed timing pattern of the first experiment is characteristic of prehensile movements of the paretic arm or represents a movement strategy adapted to the disorder. The results of the second experiment showed that subjects could comply with the instruction by reducing the absolute duration of both phases of the prehensile movement. Furthermore, the anticipation effects were eliminated to a large degree. In both experiments the time-in-contact phase was longer for the impaired limb. These results indicate a pathological constant in the time-in-contact phase for the impaired limb. This assumption is discussed in relation to the application of grip and lift forces during this phase. It is concluded that the paradigm is well suited for use in a practical setting as a simple and broad clinical test to assess the prehensile decrements of subjects with CP.

Exp Brain Res 1998 Dec;123(3):346-50 (Wang J, Stelmach GE)
"Coordination among the body segments during reach-to-grasp action involving the trunk."
    To understand the internal representations used by the nervous system to coordinate multijoint movements, we examined the coordination among the body segments during reach-to-grasp movements which involve grasping by the hand and reaching by the arm and trunk. Subjects were asked to reach and grasp an object using the arm only, the trunk only, and some combinations of both arm and trunk. Results showed that kinematic parameters related to the transport component of the arm and the trunk, such as peak velocity and time to peak velocity, varied across conditions and that the coordination pattern between the arm and trunk was different across conditions. However, parameters related to the grasp component, such as peak aperture, time to peak aperture, and closing distance, were invariant, regardless of whether the hand was delivered to the target by the arm only, the trunk only, or both. We hypothesize that a hierarchy of motor control processes exists, in which the reach and grasp components are governed by independent neuromotor synergies, which in turn are coordinated temporally and spatially by a higher-level synergy.

Harv Rev Psychiatry 1995 May-Jun;3(1):18-35 (Teicher MH)
"Actigraphy and motion analysis: new tools for psychiatry."
    Altered locomotor activity is a cardinal sign of several psychiatric disorders. With advances in technology, activity can now be measured precisely. Contemporary studies quantifying activity in psychiatric patients are reviewed. Studies were located by a Medline search (1965 to present; English language only) cross-referencing motor activity and major psychiatric disorders. The review focused on mood disorders and attention-deficit hyperactivity disorder (ADHD). Activity levels are elevated in mania, agitated depression, and ADHD and attenuated in bipolar depression and seasonal depression. The percentage of low-level daytime activity is directly related to severity of depression, and change in this parameter accurately mirrors recovery. Demanding cognitive tasks elicit fidgeting in children with ADHD, and precise measures of activity and attention may provide a sensitive and specific marker for this disorder. Circadian rhythm analysis enhances the sophistication of activity measures. Affective disorders in children and adolescents are characterized by an attenuated circadian rhythm and an enhanced 12-hour harmonic rhythm (diurnal variation). Circadian analysis may help to distinguish between the activity patterns of mania (dysregulated) and ADHD (intact or enhanced). Persistence of hyperactivity or circadian dysregulation in bipolar patients treated with lithium appears to predict rapid relapse once medication is discontinued. Activity monitoring is a valuable research tool, with the potential to aid clinicians in diagnosis and in prediction of treatment response.

Eur J Appl Physiol 1998 Aug;78(3):219-25 (Wickham JB, Brown JM)
"Muscles within muscles: the neuromotor control of intra-muscular segments."
    The aim of this investigation was to anatomically identify, and then determine the function of, individual segments within the human deltoid muscle. The anatomical structure of the deltoid was determined through dissection and/or observation of the shoulder girdles of 11 male cadavers (aged 65-84 years). These results indicate that the deltoid consists of seven anatomical segments (D1-D7) based upon the distinctive arrangement of each segment's origin and insertion. Radiographic analysis of a cadaveric shoulder joint suggested that only the postero-medial segment D7 has a line of action directed below the shoulder joint's axis of rotation. The functional role of each individual segment was then determined utilising an electromyographic (EMG) technique. Seven miniature (1 mm active plate; 7 mm interelectrode distance) bipolar surface electrodes were positioned over the proximal portion of each segment's muscle belly in 18 male and female subjects (18-30 years). EMG waveforms were then recorded during the production of rapid isometric shoulder abduction and adduction force impulses with the shoulder joint in 40 degrees of abduction in the plane of the scapula. Each subject randomly performed 15 abduction and 15 adduction isometric force impulses following a short familiarisation period. All subjects received visual feed back on the duration and amplitude of each isometric force impulse produced via a visual force-time display which compared subject performance to a criterion force-time curve. Movement time was 400 ms (time-to-peak isometric force) at an intensity level of 50% maximal voluntary contraction. Temporal and intensity analyses of the EMG waveforms, as well as temporal analysis of the isometric force impulses, revealed the neuromotor control strategies utilised by the CNS to control the activity of each muscle segment. The results showed that segmental neuromotor control strategies differ across the breadth of the muscle and that individual segments of the deltoid can be identified as having either "prime mover", "synergist", "stabiliser" or "antagonist" functions; functional classifications normally associated with whole muscle function. Therefore, it was concluded that the CNS can "fine tune" the activity of at least six discrete segments within the human deltoid muscle to efficiently meet the demands of the imposed motor task.

Brod TM: "Notes on brainwave biofeedback for young people: AD/HD and related issues". in Incorvia JA, Mark-Goldstein BS, and Tessmer D (eds): Understanding, Diagnosing And Treating AD/HD Children And Adolescents. Jason Aronson 1999

Chabot RJ, diMichele F, Prichep L, John ER: "The clinical role of computerized EEG in the evaluation and treatment of learning and attention disorders in children and adolescents". J Neuropsychiatry and Clin Neuroscience, 2001; 13: 171-186

Egner T, Gruzelier JH  "Learned self-regulation of EEG frequency components affects attention and event-related brain potentials in humans."  Neuroreport 2001, 12:411-415

Fisher S Riding the Waves: Neurofeedback: A breakthrough with learning disabilities?"  Psychotherapy Networker, Sept/October, 77-83. 2004  (click here for full article)

Fuchs T, Birbaumer N, Lutzenberger W, Gruzielier JH, Kaiser J,  "Neurofeedback treatment for ADHD in children: a comparison with methylphenidate", Appl Psychophys Biofeedback 2003 Mar 28 (1):1-12

Gruzelier, J & Egner,T. "Critical validation studies of neurofeedback". Child Adolesc Psychiatric Clinics N Am 2005; 83-104.

Hammond DC:  "Medical justification for neurofeedback with ADD/ADHD."  Journal of Neurotherapy, 2000; 4(1), 90-93.

Hirshberg LM, Chiu S, Frazier JA., "Emerging brain-based interventions for children and adolescents: overview and clinical perspective."  Child Adolesc Psychiatr Clin N Am. 2005 Jan;14(1):1-19, v  

Jarusiewicz, B. "Efficacy of Neurofeedback for Children in the Autistic Spectrum:  A Pilot Study,"  Journal of Neurotherapy, 2002; Vol 6(4), 39-49

Kaiser DA,  Othmer S: "Effect of Neurofeedback on variables of attention in a large multi-center trial."  Journal of Neurotherapy, 2000 4(1), 5-15.

Levesque J, Beauregard M, Mensour B.:  "Effect of neurofeedback training on the neural substrates of selective attention in children with ADD/ADHD: A functional MRI study."   Neurosci Lett. 2006 Feb 20;394(3):216-21.

Loo SK, "EEG and neurofeedback findings in ADHD" The ADHD Report, 2003,. 11:3, 1-4

Loo SK, Barkley RA: "Clinical Utility of EEG in ADHD."  Applied Neuropsychology 2005, Vol. 12, 64-76

Lubar JF: "Neocortical Dynamics: implications for understanding the role of neurofeedback and related techniques for the enhancement of attention."  Applied Psychophysiology and Biofedback, 1997 22: 111-25.

Lubar JF and Lubar JO: "Neurofeedback assessment and treatment for attention deficit/hyperactivity disorders".  in Evans JR and Abarbanel A (eds): Introduction to Quantitative EEG and Neurofeedback Academic Press 1999

Monastra VJ,  "Electroencephalographic biofeedback (neurotherapy) as a treatment for attention deficit hyperactivity disorder: rationale and empirical foundation."  Child Adolesc Psychiatr Clin N Am. 2005 Jan;14(1):55-82, vi.

Monastra VJ, Lubar JF, Linden M: "The development of a quantitative electroencephalographic scanning process for attention deficit hyperactivity disorder: reliability and validation studies."  Neuropsychology, 2001 15: 136-144.

Monastra VJ., Monastra DM., & George,S. . "The effects of stimulant therapy, EEG biofeedback, and parenting style on the primary symptoms of ADHD."  Applied Psychophysiology & Biofeedback, 2002, 27(4), 231-249.

Nash JK, "Treatment of ADHD with neurotherapy." Clinical Electroencephalography 2000, 31(1), 30-37

Pulvermuller F, Mohr, Schleichert H, Veit, R: "Operant conditioning of left hemispheric slow cortical potentials and its effect on word processing."  Biological Psychology, 2000; 53, 177-215.

Rosenfeld JP: "An EEG Biofeedback Protocol for Affective Disorders."  Clin Electroencephalography 2000:7-12

Rossiter, T.R., & La Vaque, T.J. "A comparison of EEG biofeedback and psychostimulants in treating attention deficit/hyperactivity disorder."  Journal of  Neurotherapy, . 1995; 1, 48-59

Sterman MB: "Physiological origins and functional correlates of EEG rhythmic activities: implications for self-regulation". Biofeedback and Self-Regulation 1996 21:3-34

Thompson L, Thompson M. "Neurofeedback combined with training in metacognitive strategies: effectiveness in students with ADD." Appl Psychophysiol Biofeedback. 1998 Dec;23(4):243-63.

Tinius TP, Tinius KA:  "Changes after EEG biofeedback and cognitive retraining in adults with mild traumatic brain injury and attention deficit disorder."  Journal of Neurotherapy, 2001; 4(2), 27-44.  (must go half way down the page to find abstract)

Vernon D, Egner T, Cooper N, Compton T, Neilands C, Sheri A, Gruzielier J, "The effect of training distinct neurofeedback protocols on aspects of cognitive performance."  Intl J Psychophys, 2003, 47: 75-86
 

Al-Bdour MD, Odat TA, Tahat AA. “Myopia and level of education.” Eur J Ophthalmol, 2001 Jan-Mar; 11(1):1-5
    Purpose: To find out whether the development of myopia is related to the level of education. Methods: From two big ophthalmic outpatient clinics in Jordan, 968 subjects (between the age of 24 and 45 years) were included in this study. A subject was considered myopic if at least one eye had a spherical equivalent refractive error of at least -0.75 diopter. The subjects were divided into two groups: the educated group was those who had finished at least 12 years of education and the non-educated which included those with maximum of six years of education. There were 468 men and 500 women. Results: The frequency of myopia was higher in the educated group in both men and women. A significant relationship was found between the level of education and myopia in the whole study group (p<0.0001). Conclusions: This study had too few subjects to draw general conclusions, but within the study group there was a significant relationship between the level of education and the development of myopia.

Bobier WR, Sivak JG. "Orthoptic treatment of subjects showing slow accommodative responses."  Am J Optom Physiol Opt, 60:678-87, 1983.
    Abstract: Five subjects showing slow accommodative responses were given optometric vision therapy. Speed of accommodative response improved after 3 to 6 weeks.  No regressions were evident 18 weeks after the cessation of training.  The results of the study indicate that optometric vision therapy is effective in improving slow accommodative responses.

Borsting E., Rouse MW, et al. "Association of Symptoms and Convergence and Accommodative Insufficiency in School-Age Children." Optometry 2003; 74: 25-34.
    Abstract:  It was found that Accommodative Insufficiency is common among children aged 8-15 and associated with definite symptoms.  This study included 392 children.

Ciuffreda, KJ. "The Scientific Basis for and Efficacy of Optometric Vision Therapy in Nonstrabismic Accommodative and Vergence Disorders." Optometry 2002; 73: 735-62.
    Abstract:  Using bio-engineering models of the oculomotor system as the conceptual framework, findings clearly support the validity of optometric vision therapy. Furthermore, the results are consistent with the tenets of general motor learning.

Cooper J, Fledman J, Selenow A, et al. "Reduction of asthenopia after accommodative facility training."  Am J Optom Physiol Opt, 64:430-6, 1987.
    Abstract: Five patients reporting asthenopia (eye strain) secondary to accommodative deficiencies underwent automated monocular accommodative facility training.  A matched-subjects, crossover design was used to control for placebo effects.  All patients receiving automated accommodative training showed a marked increase in accommodative amplitude along with a concurrent reduction of asthenopia.  Decreases of blur and increases of reading time were the most frequently reported changes by patients.  This experiment shows the effectiveness of automated accommodative training in reducing asthenopia and improving accommodative facility.

Daum KM. "Accommodative insufficiency." Am J Optom Physiol Opt, 60:352-9, 1983.
    Abstract: A retrospective review of the records of 96 patients with accommodative insufficiency was conducted. The results of orthoptic exercises and/or a plus lens addition at near were examined.  Most patients (90%) obtained some relief with treatment.  About 53% had their objective and subjective problems totally solved during an average treatment period of 3.7 weeks.

Hung GK, Ciuffreda KJ, Semmlow JL. "Static vergence and accommodation: population norms and orthoptics effects." Doc Opthalmologica 62:15-79, 1986.
    Abstract: This study investigated the effect of orthoptic therapy lasting 8-16 weeks on the accommodative and vergence system function of 22 visually-normal asymptomatic individuals and 21 visually-abnormal symptomatic individuals. Following therapy, asymptomatic individuals experienced reduction of symptoms and improvement in visual parameters toward the normal mean function.

Hoffman LG.  "The effect of accommodative deficiencies on the developmental level of perceptual skills."  Am J Optom Physiol Opt, 59:254-62, 1982.
    Abstract: The relation of accommodative to visual-motor perceptual abilities was investigated.  Patients between 5 and 13 years of age manifesting both accommodative and visual-motor perceptual deficits were given accommodative therapy.  The effect of this therapy was analyzed, and the results indicated that improvement in the visual and motor perceptual abilities occurred in the 5 to 7 years, 11 month age group.

Liu JS, Lee M, Jang J, et al. "Objective assessment of accommodation orthoptics. 1. Dynamic Insufficiency."  Am J Optom Physiol Opt, 56:285-94, 1979.
    Abstract: Three young adult females with symptoms related to focusing difficulties at near were treated by standard optometric vision therapy procedures.  Home training was done 20 minutes each day for 4 1/2 – 7 weeks.  Objective measures of dynamic accommodation were made each week.  During treatment, the patients showed significant reductions in time constants and latencies that correlated well with elimination of subjective symptoms.  Also, in all three patients, symptoms were either markedly diminished or no longer present at termination of therapy. These results clearly demonstrate that optometric vision therapy resulted in objective improvement of accommodation function.

London R, Wick B, Kirschen D. "Post-Traumatic Pseudomyopia." Optometry. 2003 Feb;74(2):111-20.
    BACKGROUND: Many clinicians have noted that patients demonstrate a myopic refractive change following Traumatic Brain Injury (TBI).  This apparent myopic shift disappears with cycloplegia, yet stubbornly reappears as soon as the pharmaceutical effect wears off.  We propose that this shift is secondary to an irritative lesion that affects the parasympathetic innervation, resulting in ciliary body contracture.  The dilemma for the clinician is whether to provide the immediate relief of clear distance vision by prescribing additional minus lenses, or to work toward attempting to re-establish the baseline refractive error.
    CASE REPORTS: The natural history of post-traumatic pseudomyopia in our experience involves one of the following three courses: (1) a transient condition that will occasionally resolve; (2) the typical case, a recalcitrant condition that will resolve under cycloplegic intervention, but immediately return as the cycloplegic wears off; or (3) a less-common subgroup of patients who continue to show an increase in myopia over time. Our description of these cases demonstrates management strategies (including atropinization) to relax accommodative spasm, traditional vision therapy techniques aimed at loosening the accommodative system, and refractive corrections.
    CONCLUSIONS: Pseudomyopia is one of many ocular and behavioral sequelae following TBI. By understanding the natural course and potential management options for post-traumatic pseudomyopia, the clinician will be better prepared to deal with these challenging cases.  Flexibility is required, since options that work with one patient may prove ineffective with another.  Counseling the patient as to potential outcomes given the natural history of this condition helps establish more-realistic expectations by the patients being treated.

Rouse MW  "Management of binocular anomalies: efficacy of vision therapy in the treatment of accommodative deficiencies."  Am J Optom Physiol Optics, (64):415-420, 1987
    Abstract: This paper is a review of the literature supporting optometric vision therapy as an effective treatment mode for accommodative deficiencies.  Optometric vision therapy procedures have been shown to improve accommodative function and eliminate or reduce associated symptoms.  In addition, the actual physiological accommodative response variables modified by the therapy have been identified, eliminating the possibility of Hawthorne or placebo effects accounting for treatment success.  The improved accommodative function appears to be fairly durable after treatment.

Saw SM, Wu HM, Seet B, Wong TY, Yap E, Chia KS, Stone RA, Lee L. “Academic achievement, close up work parameters, and myopia in Singapore military conscripts.” Br J Ophthalmol, 2001,07; 85(7):855-60
    Aim- To determine the relation of refractive error to environmental factors, including close up work, in Singapore military conscripts. Methods: A cross sectional study was conducted on 429 Singapore military conscripts. Non-cycloplegic refraction and A-scan biometry were performed in both eyes. A detailed questionnaire was administered by in-person interview to obtain information about current and past near work activity, extra tuition lessons, educational experiences, and family demographics. Results: Myopia associated with the conscript having been educated in the (gifted, special, or express) educational streams (adjusted odds ratio (OR) = 3.8, 95% confidence interval CI 2.0-7.3), and having completed pre-university education (OR=4.1, 95% CI 1.9-8.8). The reported close up work activity at age 7 years did correlate with age of onset of myopia (p<0.001). In parallel, supplemental tuition lessons in primary school has (OR=2.6, 95% CI 1.4-4.9) associated with conscript myopia. Parental myopia was positively associated with myopia (p<0.001), but this relation disappeared when adjusted for environmental factors. Current (p=0.83) and past close up work activity at age 7 years (p=0.13) did not correlate with myopia.  CONCLUSION: Educational level and educational stream positively related to myopia.  A relation was observed with reported close up work activity in early childhood and with tuition classes during elementary school, but not with current close up work activity.  These results underscore the strong influence of environment in myopia pathogenesis but a role for close up work activity remains indeterminate.

Sterner B, Abrahamsson M, Sjostrom A. "Accommodative facility training with a long term follow up in a sample of school aged children showing accommodative dysfunction." Doc Ophthalmol 99:93-101, 1999.
    Abstract:  The purpose of this study was to evaluate the effect of accommodative training in a group of children with accommodative dysfunction and subjective symptoms. A total of 38 symptomatic children (ages nine to thirteen) and 24 controls, participated in the study. The length of training varied from 3 to 25 weeks.  A follow-up examination was performed two years after the end of training. The study showed that it is possible to increase relative accommodative by accommodative facility training and minimize subjective symptoms. In the followup evaluation, none of the children had regained any subjective symptoms.

Stewart RE, Woodhouse JM, Trojanowska LD. “The use of bifocal spectacles with children with Down's Syndrome.” Ophthalmic and Physiological Optics,  25: 514, Nov 2005
    Purpose: Over 75% of children with Down's syndrome fail to accommodate accurately on near targets. This deficit must result in optically blurred images for near work. This present study set out to evaluate the controlled use of bifocal spectacles as an aid to near focusing. Although sometimes used clinically, no systematic studies of bifocals for children with Down's syndrome have been reported.

    Methods: This was a comparative non-randomised interventional study. Thirty-four children with Down's syndrome of primary school age (5-11 years) took part, assigned in equal numbers to form two matched groups. All children received a full optometric assessment prior to entering the study. The treatment group was prescribed bifocal spectacles with a +2.50 addition, and the control group provided with single vision lenses to correct any clinically significant refractive error. Three follow-up visits were made over a 5-month period after spectacle provision.

    Results: The treatment group showed consistently more accurate accommodation than the control group both through the bifocal segment, and, unexpectedly, through the distance part of the lens (p < 0.05).  Compliance with new spectacles was high in both groups (>82% fully compliant).

    Conclusions: Bifocals confer benefit to children with Down's syndrome who under-accommodate, both directly (better focusing through the bifocal) and indirectly (by encouraging improved accommodation through the distance part of the lens). Based on the results of this study, eye examinations of children with Down's syndrome should routinely include a measure of accommodation at near, and bifocal spectacles should be considered for those who show under-accommodation.

Suchoff IB, Petito GT.  "The efficiency of visual therapy: accommodative disorders and non-strabismic anomalies of binocular vision."  J Am Optom Assoc, 57:119-25, 1986.
    Abstract: This paper examines the available literature in order to answer the question, “Is there evidence that `orthoptics' or `vision therapy' causes changes in an individual's accommodative or vergence eye movement systems?' This review neither examines alternative methods of causing these changes nor provides information concerning which particular techniques are most effective although the literature does provide such information. The literature cited substantiates that optometric vision therapy can modify visual functions and also points out the relationship of these changes to the relief of certain symptoms.

Weisz CL.  "Clinical therapy for accommodative responses: transfer effects upon performance."  J Am Optom Assoc, 50:209-12, 1979.
    Abstract: A clinical therapy program featuring accommodative training was administered to a group of children with diagnosed disorders of accommodative function. The children ranged in age from six to twelve years. A group of subjects representing the same clinical population, and not differing significantly in age or grade level, acted as a control group. The control subjects participated in a therapy program of a similar duration, wherein perceptual-motor training (unrelated to the training of accommodative skills) was administered. A nearpoint pencil-and-paper task was administered to all subjects before and after their training programs, to assess changes in performance as a criterion of learning transfer and behavioral generalization. A significantly greater decrease in errors occurred in the group receiving the accommodative training as contrasted to the control group. No significant differences were found in the time scores. The results suggest that accommodative training, for children with diagnosed accommodative disorders, had transfer effects upon nearpoint performance relating to improved accuracy.

Wold, RM, Pierce JR, Keddington, J "Effectiveness of optometric vision therapy." J Amer Optom Assoc, 49:1047-1059, 1978
    Eighty out of 100 children improved in accommodative amplitude (the ability to focus on close objects) and 76 improved in accommodative facility (the ability to adjust focus from near to far) after vision therapy.

Wolffsohn JS, Gilmartin B, Thomas R, Mallen EA. “Refractive error, cognitive demand and nearwork-induced transient myopia.” Curr Eye Res. 2003 Dec;27(6):363-70.
    PURPOSE: Whereas many previous studies have identified the association between sustained near work and myopia, few have assessed the influence of concomitant levels of cognitive effort. This study investigates the effect of cognitive effort on near-work induced transient myopia (NITM).
    METHODS: Subjects comprised of six early onset myopes (EOM; mean age 23.7 yrs; mean onset 10.8 yrs), six late-onset myopes (LOM; mean age 23.2 yrs; mean onset 20.0 yrs) and six emmetropes (EMM; mean age 23.8 yrs). Dynamic, monocular, ocular accommodation was measured with the Shin-Nippon SRW-5000 autorefractor. Subjects engaged passively or actively in a 5 minute arithmetic sum checking task presented monocularly on an LCD monitor via a Badal optical system. In all conditions the task was initially located at near (4.50 D) and immediately following the task instantaneously changed to far (0.00 D) for a further 5 minutes. The combinations of active (A) and passive (P) cognition were randomly allocated as P:P; A:P; A:A; P:A.
    RESULTS: For the initial near task, LOMs were shown to have a significantly less accurate accommodative response than either EOMs or EMMs (p < 0.001). For the far task, post hoc analyses for refraction identified EOMs as demonstrating significant NITM compared to LOMs (p < 0.05), who in turn showed greater NITM than EMMs (p < 0.001). The data show that for EOMs the level of cognitive activity operating during the near and far tasks determines the persistence of NITM; persistence being maximal when active cognition at near is followed by passive cognition at far.
    CONCLUSIONS: Compared with EMMs, EOMs and LOMs are particularly susceptible to NITM such that sustained near vision reduces subsequent accommodative accuracy for far vision. It is speculated that the marked NITM found in EOM may be a consequence of the crystalline lens thinning shown to be a developmental feature of EOM. Whereas the role of small amounts of retinal defocus in myopigenesis remains equivocal, the results show that account needs to be taken of cognitive demand in assessing phenomena such as NITM.

Wolffsohn B, Gilmartin B, Wing-hong Li R, Hastings Edwards M,  Wing-shan Chat S, Kwok-fai Lew J,  Sin-ying Yu, B. "Nearwork-Induced Transient Myopia in Preadolescent Hong Kong Chinese."  Investigative Ophthalmology and Visual Science. 2003;44:2284-2289.
    PURPOSE. To compare the magnitude and time course of nearwork-induced transient myopia (NITM) in preadolescent Hong Kong Chinese myopes and emmetropes.  
    METHOD. Forty-five Hong Kong Chinese children, 35 myopes and 10 emmetropes aged 6 to 12 years (median, 7.5), monocularly viewed a letter target through a Badal lens for 5 minutes at either 5.00- or 2.50-D accommodative demand, followed by 3 minutes of viewing the equivalent target at optical infinity. Accommodative responses were measured continuously with a modified, infrared, objective open-field autorefractor. Accommodative responses were also measured for a countercondition: viewing of a letter target for 5 minutes at optical infinity, followed by 3 minutes of viewing the target at a 5.00-D accommodative demand. The results were compared with tonic accommodation and both subject and family history of refractive error.  
    RESULTS. Retinal-blur–driven NITM was significantly greater in Hong Kong Chinese children with myopic vision than in the emmetropes after both near tasks, but showed no significant dose effect. The NITM was still evident 3 minutes after viewing the 5.00-D near task for 5 minutes. The magnitude of NITM correlated with the accommodative drift after viewing a distant target for more than 4 minutes, but was unrelated to the subjects’ or family history of refractive error.
    CONCLUSIONS. In a preadolescent ethnic population with known predisposition to myopia, there is a significant posttask blur-driven accommodative NITM, which is sustained for longer than has previously been found in white adults.

Barrett BT, Bradley A, McGraw PV. "Understanding the neural basis of amblyopia." Neuroscientist. 2004 Apr;10(2):106-17.
    Amblyopia is the condition in which reduced visual function exists despite full optical correction and an absence of observable ocular pathology. Investigation of the underlying neurology of this condition began in earnest around 40 years ago with the pioneering studies conducted by Hubel and Wiesel. Their early work on the impact of monocular deprivation and strabismus initiated what is now a rapidly developing field of cortical plasticity research. Although the monocular deprivation paradigm originated by Hubel and Wiesel remains a key experimental manipulation in studies of cortical plasticity, somewhat ironically, the neurology underlying the human conditions of strabismus and amblyopia that motivated this early work remains elusive. In this review, the authors combine contemporary research on plasticity and development with data from human and animal investigations of amblyopic populations to assess what is known and to reexamine some of the key assumptions about human amblyopia.

Barrett BT, Pacey IE, Bradley A, Thibos LN, Morrill P., "Nonveridical visual perception in human amblyopia." Invest Ophthalmol Vis Sci 2003 Apr;44(4):1555-67
    PURPOSE: Amblyopia is a developmental disorder of spatial vision. There is evidence to suggest that some amblyopes misperceive spatial structure when viewing with the affected eye. However, there are few examples of these perceptual errors in the literature. This study was an investigation of the prevalence and nature of misperceptions in human amblyopia.
    METHODS: Thirty amblyopes with strabismus and/or anisometropia participated in the study. Subjects viewed sinusoidal gratings of various spatial frequencies, orientations, and contrasts. After interocular comparison, subjects sketched the subjective appearance of those stimuli that had nonveridical appearances.
    RESULTS: Nonveridical visual perception was revealed in 20 amblyopes ( approximately 67%). In some subjects, misperceptions were present despite the absence of a deficit in contrast sensitivity. The presence of distortions was not simply linked to the depth of amblyopia, and anisometropes were affected as well as those with strabismus. In most cases, these spatial distortions arose at spatial frequencies far below the contrast detection acuity cutoff. Errors in perception became more severe at higher spatial frequencies, with low spatial frequencies being mostly perceived veridically. The prevalence and severity of misperceptions were frequently found to depend on the orientation of the grating used in the test, with horizontal orientations typically less affected than other orientations. Contrast had a much smaller effect on misperceptions, although there were cases in which severity was greater at higher contrasts.
    CONCLUSIONS: Many types of misperceptions documented in the present study have appeared in previous investigations. This suggests that the wide range of distortions previously reported reflect genuine intersubject differences. It is proposed that nonveridical perception in human amblyopia has its origins in errors in the neural coding of orientation in primary visual cortex.

Birnbaum MH, Koslowe K, Sanet R. "Success in amblyopia therapy as a function of age: A literature survey." Am J Optom & Physiol Optics, 54(5): 269-275, 1977.
     It is frequently stated that amblyopia is not correctable after the age of 6 years. However, many practitioners report marked success for older patients. To evaluate these conflicting reports, this study analyzed the results from 23 published amblyopia studies. The analysis indicates that substantial numbers of patients over age six were successfully treated. Success rates under age 6 were not significantly better than those in older patients when the criterion for success was achievement of 20/30 acuity or better. When a criterion of 4 lines improvement was used, success rates at all ages under 16 were quite similar; in patients 16 and over, success by this criterion was significantly less frequent, but even in this group success was achieved by 42% of the patients.

Cotter SA. "Conventional therapy for amblyopia." Problems in Optometry, RP Rustein (ed), 3(2): 312, 1991.
     Conventional treatment of amblyopia involves appropriate refractive correction, occlusion of the dominant eye, and active vision therapy. The specific occlusion regimen is determined based on the patient's age, binocular status, acuity level, and performance needs. Successful amblyopia treatment is dependent on several factors, of which patient compliance is the most important. There is no evidence that treatment should be with held on the basis of age. Close follow-up is essential and maintenance therapy is often necessary.

Dobson V, Miller JM, Harvey EM, Mohan KM  "Amblyopia in astigmatic preschool children." Vision Research, Volume 43, Issue 9, April 2003, 1081-1090
     Best-corrected acuity was measured for vertical and horizontal gratings and for recognition acuity optotypes (Lea Symbols) in a group of three- to five-year-old children with a high prevalence of astigmatism.  Results showed meridional amblyopia (MA) among children with simple/compound myopic or mixed astigmatism, due to reduced acuity for horizontal gratings.  Children with simple/compound hyperopic astigmatism showed no MA, but did show reduced acuity for both grating orientations.  Reduced best-corrected recognition acuity was shown by both myopic/mixed and hyperopic astigmats.  These results suggest that optical correction of astigmatism should be provided prior to age three to five years, to prevent development of amblyopia. 

Garzia RP. "Efficacy of vision therapy in amblyopia: A literature review." Am J Optom & Physiol, 64(6): 393-404, 1987
    In this paper the major optometric, ophthalmologic, and orthoptic literature on the efficacy of vision therapy for amblyopia was surveyed. Over the past four decades there are many examples of the successful treatment of amblyopia in the form of well documented individual case reports or large sample studies.  Although occlusion of the dominant eye has been applied universally, there are some instances of the successful use of minimal occlusion combined with extensive visual-motor therapy.  Overall, the results of the literature review strongly support the use for active vision therapy as an integral part of the clinical treatment of amblyopia.

Hokoda SC, Ciuffreda KJ. "Different rates and amounts of vision function recovery during orthoptic therapy in an older strabismic amblyope." Ophthal & Physiol Opt, 6(2): 213-220, 1986.
     Orthoptic therapy was instituted in an 11-year-old patient having deep amblyopia, a constant small-angle esotropia with anomalous retinal correspondence, and a past history of minimal success with such therapy. This combination of factors pointed toward a poor prognosis for substantial recovery of vision functions. Rate of recovery of several monocular and binocular vision functions was monitored during the course of 18 months of intensive orthoptic therapy. Results showed marked improvement in several monocular vision functions, suggesting presence of considerable residual neural plasticity of multiple sites in the visual pathways of this older patient with amblyopia.

Koskela PU, Mikkola T, Laatikainen L. "Permanent results of pleoptic treatment." ACTA Ophthalmologica, 69: 39-44, 1991.
     The value of pleoptic treatment was assessed by long-term follow-up of patients treated 15-22 years ago, employing a questionnaire sent of 232 patients and a clinical examination of a sample of 44 of these. Answers were received from 157 persons with different occupations and educational levels. The poorest results were found in the combined strabismic and anisometropic amblyopia group. The final VA correlated positively with the initial VA and negatively with age at the time of treatment. Binocular single vision improved the prognosis. Altogether ¼ of the patients achieved a VA of 1.0 or better, about one half experienced no permanent increase in VA and the remainder were distributed evenly between these two extremes.

Krumholtz I, FitzGerald D. "Efficacy of treatment modalities in refractive amblyopia." J am Optom Assoc, 70(6):399-404, 1999.
     A retrospective review was performed of 78 patients diagnosed with refractive amblyopia.  Each patient's progress was tracked for a period of 6 months. Treatment alternatives were optical correction alone, optical correction in conjunction with patching, and optical correction and patching with vision therapy. The groups that patched with correction and those that received vision therapy had similar visual activity improvements; however, the latter group had a significantly greater improvement in stereopsis. Though patching alone may be sufficient for improvement of visual activity, binocular performance is significantly better when vision therapy is included in the treatment regimen.

Mintz-Hittner HA, Fernandez KM. "Successful amblyopia therapy initiated after age 7 years.  Arch Ophthalmol 118(11):1535-41, 2000.
     This article reports successful therapy for anisometropic and strabismic amblyopia initiated after age 7 years. A consecutive series of 36 compliant children older than 7 years (range, 7.0 to 10.3 years; mean, 8.2 years) at initiation of amblyopia therapy for anisometropic (19 patients; mean age, 8.3 years), strabismic (9 patients; mean age, 8.0 years), or anisometropic and strabismic (8 patients; mean age, 8.0 years) amblyopia was studied. Initial (worst) visual acuities were between 20/50 and 20/400 (log geometric mean, -0.83 [antilog, 20/134] for all patients; -0.88 [antilog, 20/151] for anisometropic patients; -0.70 [antilog, 20/100] for strabismic patients; and -0.88 [antilog, 20/151] for anisometropic and strabismic patients). Initial (worst) binocularity was absent or reduced in all cases. Therapy consisted of (1) full-time standard occlusion (21 patients; mean age, 8.0 years), (2) total penalization (7 patients; mean age, 7.8 years), or (3) full-time occlusive contact lenses (8 patients; mean age, 8.8 years). Final (best) visual acuities were between 20/20 and 20/30 for all 36 patients. Final (best) binocularity was maintained or improved for 22 (61 percent) of 36 patients, including 16 anisometropic patients (84 percent), 2 strabismic patients (22 percent), and 4 anisometropic and strabismic patients (50 percent). Given compliance, therapy for anisometropic and strabismic amblyopia can be successful even if initiated after age 7 years.

Mitchell DE, Howell ER and Keith CG. "The effect of minimal occlusion therapy on binocular visual functions in amblyopia." Invest. Ophthalmol. Vis. Sci. 1983 24: 778-781.   
    The binocular visual functions of amblyopic children were studied during treatment involving brief weekly periods of occlusion of the unaffected eye while the child performed demanding visuomotor tasks against either a background of rotating gratings or a stationary uniform gray stimulus. The gains in stereoacuity were quite significant and in most cases more obvious than the rather small gains in letter visual acuity. On initial presentation only 21 of the 60 patients showed evidence of stereopsis and of these only seven possessed a stereoacuity of 100 secs or better. Following six treatment sessions the number of patients that demonstrated stereopsis increased to 36 of whom 17 possessed reasonably good stereoacuity (100 secs or better). However, there was no difference in the degree of improvement exhibited by those patients that viewed rotating grating patterns during treatment and others from the control group that viewed the uniform gray stimulus. Thus, there was no evidence that any of the visual gains were enhanced or promoted by active visual stimulation of the amblyopic eye with rotating gratings during the brief periods of occlusion of the unaffected eye. Finally, a comparison of the scores of the children on various stereo-tests suggest that tests comprised of small figure elements that are present in high density may be best for screening purposes. On the other hand, for quantifying the stereoacuity of children known to possess abnormal binocular vision it may be more appropriate to employ tests that use large figure elements that provide strong fusion cues.

Mohan K, Saroha V, Sharma, A. "Successful Occlusion Therapy for Amblyopia in 11 to 15 Year Old Children."  Journal of Pediatric Ophthalmology and Strabismus  41:#2 p. 89-95 March/April 2004
    Purpose:  To investigate the effectiveness of fulltime occlusion therapy in treating amblyopia in 11- to 15-year-old children and to determine its lasting results.
    Patients & Methods:  Fifty-five compliant children 11 to 15 years old who had amblyopia were treated with full-time (during all waking hours) occlusion of their good eye until no further improvement in the visual acuity of their amblyopic eye was observed on 3 consecutive monthly follow-up examinations. After this, part-time (4 hours per day) occlusion therapy was used randomly in 24 of 55 patients for 3 to 6 months for maintenance of the final visual acuity. Snellen visual acuity and its logMAR equivalent were recorded before treatment, at the cessation of full-time occlusion therapy, and on the most recent examination.
    Results: All 55 of the patients had improved visual acuity after treatment. The mean improvement was 0.46 logMAR unit (4.6 Snellen lines). Thirty-two of the patients had a mean follow-up of 17.6 months after the cessation of full-time and maintenance occlusion therapy. Twentynine (91%) of the 32 patients maintained improved visual acuity, whereas 3 (9%) exhibited a regression in visual acuity. Maintenance occlusion therapy did not have a significant stabilizing effect on the improved visual acuity.
    Conclusion: Compliant, full-time occlusion effectively improves acuity in children 11 to 15 years old who have amblyopia due to strabismus, anisometropia, or both. Most older patients have lasting improvement with or without maintenance patching.

Pediatric Eye Disease Investigator Group "A randomized trial of patching regimens for treatment of moderate amblyopia in children."  Arch Ophthalmol 121:603-611, 2003.
     In a randomized multicenter (35 sites) clinical trial, 189 children younger than 7 years with amblyopia in the range of 20/40 to 20/80 were assigned to receive either 2 hours or 6 hours of daily patching combined with at least 1 hour of near visual activities during patching.  When combined with prescribing 1 hour near visual activities, 2 hours of patching produces an improvement in visual acuity that is of similar magnitude to the improvement produced by 6 hours of daily patching in treating moderate amblyopia in children aged 3 to 7 years.

Pediatric Eye Disease Investigator Group "A randomized trial of atropine vs patching for treatment of moderate amblyopia in children."  Arch Ophthalmol 120:268-278, 2002.
     Amblyopia is the most common cause of monocular visual impairment in both children and young and middle-age adults. In a randomized clinical trial, 419 children younger that 7 years with amblyopia and visual acuity in the range of 20/40 to 20/00 were assisted to receive with patching or atropine eye drops at 47 clinical centers. Atropine and patching produce improvement of similar magnitude, and both are appropriate modalities for the initial treatment of moderate amblyopia in children aged 3 to less than 7 years.

Polat U, Ma-Naim T. Melking M, Sagi D.,"Improving Vision in Adult Amblyopia by Perceptual Learning."  PNAS (Proceeding of National Academy of Sciences) 101:6692-7, 2004
    Practicing certain visual tasks leads, as a result of a process termed ‘‘perceptual learning,’’ to a significant improvement in performance.  Learning is specific for basic stimulus features such as local orientation, retinal location, and eye of presentation, suggesting modification of neuronal processes at the primary visual cortex in adults. It is not known, however, whether such low-level learning affects higher-level visual tasks such as recognition. By systematic low-level training of an adult visual system malfunctioning as a result of abnormal development (leading to amblyopia) of the primary visual cortex during the ‘‘critical period,’’ we show here that induction of low-level changes might yield significant perceptual benefits that transfer to higher visual tasks. The training procedure resulted in a 2-fold improvement in contrast sensitivity.

Rutstein RP, Fuhr PS. "Efficacy and stability of amblyopia therapy." Optom & Vis Sci, 69(1): 747-754, 1992.
     To determine the efficacy and stability of therapy, the charts for 64 amblyopes with strabismus and /or anisometropia who had been treated by direct occlusion were reviewed. For patients aged 7 years or less (N=39), 90% showed some acuity gain, with 69% achieving at least a doubling of acuity. Fifty-four percent obtained 20/40 or better after an average treatment period of 3.8 months. Some reduction in visual acuity (VA) subsequently occurred for 75% of those patients followed. For patients aged eight years or more (N=26), 77% showed some acuity gain with 31% (8/260 improving at least 0.3 log units. Twenty-seven percent obtained 20/40 (6/12) or better after an average treatment period of 4.2 months, although no patients older than 10 years (N=13) achieved 20/40 . Loss of some of the acuity gain subsequently occurred for 67% of those followed. These findings indicate that VA can be improved by patching therapy in most patients older than 7 years, but the acuity improvement is somewhat less than in younger patients. At least 67% of all amblyopes followed for one year lost some of the acuity gain after cessation of therapy, regardless of the age when treated. As a reduction of the acuity gain is likely to occur within the first year after cessation of therapy, it is recommended that amblyopic patients of all ages be followed at regular intervals.

Saulles H. "Treatment of refractive amblyopia in adults." J Amer Optom Assoc, 58(12): 959-960, 1987.
     Treatment of amblyopia has been relatively ignored in the adult population. In a retrospective study at the University of Michigan Health Service, 10 patients with refractive amblyopia showed visual acuity improvement in their amblyopic eye after completing simple vision therapies.

Selenow A, Ciuffreda KJ. "Vision function recovery during orthoptic therapy in an adult esotropic amblyope." J Amer Optom Assoc, 57(2); 132-140, 1986.
     Orthoptic therapy was instituted in a 29-year-old patient having moderate amblyopia, constant small-angle esotropia, and large and steady eccentric fixation. This combination of factors, especially the age, pointed toward a poor prognosis for attainment of markedly improved vision function. Rate of recovery of several monocular vision functions was monitored during one year of orthopic therapy. Results showed substantial improvement in most areas, thus providing evidence of neural plasticity at multiple sites in the visual pathways in this adult amblyope.

Selenow A, Ciuffreda KJ. "Vision function recovery during orthoptic therapy in an exotropic amblyope with high unilateral myopia." Am J Optom & Physiol Optics, 60(8): 659-666, 1983.
     Orthoptic therapy was instituted in a 6 ½-year-old patient having deep amblyopia, constant exotropia, and high unilateral myopia. The combination of these factors pointed toward poor prognosis for attainment of normal monocular and binocular vision function. Rates of recovery of several vision functions were monitored during orthoptic therapy. Results showed marked improvement in most areas, thus providing evidence of neural plasticity at multiple sites in the visual pathways.

Webber, A.L.,1 Wood, J.M.,1 Gole, G.A.,2 and Brown, B.1  (1From the School of Optometry and Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Queensland, Australia; and the 2Department of Paediatrics and Child Health, University of Queensland, Herston, Queensland, Australia) "The Effect of Amblyopia on Fine Motor Skills in Children." Investigative Ophthalmology and Visual Science. 49:594-603, 2008.
    PURPOSE. In an investigation of the functional impact of amblyopia in children, the fine motor skills of amblyopes and age-matched control subjects were compared. The influence of visual factors that might predict any decrement in fine motor skills was also explored.
    METHODS. Vision and fine motor skills were tested in a group of children (n = 82; mean age, 8.2 ± 1.7 [SD] years) with amblyopia of different causes (infantile esotropia, n = 17; acquired strabismus, n = 28; anisometropia, n = 15; mixed, n = 13; and deprivation n = 9), and age-matched control children (n = 37; age 8.3 ± 1.3 years). Visual motor control (VMC) and upper limb speed and dexterity (ULSD) items of the Bruininks-Oseretsky Test of Motor Proficiency were assessed, and logMAR visual acuity (VA) and Randot stereopsis were measured. Multiple regression models were used to identify the visual determinants of fine motor skills performance.
    RESULTS. Amblyopes performed significantly poorer than control subjects on 9 of 16 fine motor skills subitems and for the overall age-standardized scores for both VMC and ULSD items (P < 0.05). The effects were most evident on timed tasks. The etiology of amblyopia and level of binocular function significantly affected fine motor skill performance on both items; however, when examined in a multiple regression model that took into account the intercorrelation between visual characteristics, poorer fine motor skills performance was associated with strabismus (F1,75 = 5.428; P = 0.022), but not with the level of binocular function, refractive error, or visual acuity in either eye.
    CONCLUSIONS. Fine motor skills were reduced in children with amblyopia, particularly those with strabismus, compared with control subjects. The deficits in motor performance were greatest on manual dexterity tasks requiring speed and accuracy.

Wick B, Wingard Ml  "Anisometropic amblyopia: Is the patient ever too old to treat?" Optom & Vis Sci, 69(11): 866-878, 1992.
     This report describes a sequential management program for anisometropic amblyopia that consists of four steps: (1) the full refractive correction, (2) added lenses or prism when needed to improve alignment of the visual axes, (3) 2 to 5 hour/day of direct occlusion and (4) active vision therapy to develop monocular acuity and improve binocular visual function. The records of 19 patients over six years of age who had been treated using this sequential management philosophy were evaluated. After 15.2 weeks of treatment the Amblyopia Success Index (ASI) documented an average improvement in visual acuity of 92.1% with a range from a low of 75% by a 49-year-old patient to a maximum of 100% achieved by 42.1% of the patients (8 of 19). Patients who had completed therapy one or more years ago (N=4) maintained their acuity improvement. From these results, we conclude that following a sequential management plan for treatment of anisometropic amblyopia can yield substantial long-lasting improvement in visual acuity and binocular function for patients of any age.

Atzmon D, Nemet P, et al "A randomized prospective masked and matched comparative study of orthoptic treatment versus conventional reading tutoring treatment for reading disabilities in 62 children." Binoc Vision & Eye Muscle Surgery Qtrly, (8):91-106, 1993
    Reading improved in children with reading disabilities when they were given vision therapy. The treatment was as effective as reading practice.