Supplement · not part of the AOTA-approved activity
Visual performance for physical therapy
For PT, DPT, PTA · Certificate of Participation
Vision is a postural and navigational system before it is an academic one. A child who slows on uneven ground, hugs the rail, or loses balance when the head moves may be managing a visual performance problem with a motor strategy. This supplement gives you the language for that, the referral rules, and the session modifications that stop visual load from masking motor progress.
Gaze stabilization is not oculomotor efficiency
Both look like "trouble with the eyes" and they behave differently under load. Keeping the distinction clear protects your documentation.
- Gaze stabilization: a target blurs or the room seems to move when the head moves; symptoms scale with head velocity.
- Oculomotor efficiency: the head is still and the eyes cannot sustain accurate fixation, tracking, or shifting; symptoms scale with duration.
- Test head-still first. If accuracy is already breaking down without head movement, you are not looking at a vestibular-only problem.
- Document the provoking variable — velocity or duration — rather than a global "visual complaints".
Balance, postural control, and visual dependence
Some children hold posture with vision because the other systems are not yet reliable. Removing vision reveals it in seconds.
- Compare eyes-open and eyes-closed stance, and firm versus compliant surface, and record the difference rather than a pass or fail.
- A large eyes-closed decrement means the child is visually dependent; grade the visual demand rather than removing it abruptly.
- Watch for a widened base, fixed head, or reduced head turning during gait — these are compensations worth naming.
- Reduce visual clutter in the treatment space before concluding that attention is the limiting factor.
Concussion and return to activity
Visual symptoms are among the most common and most persistent post-concussion complaints, and visual load is the variable you can grade precisely.
- Screen for symptom provocation before loading; stop at meaningful symptom increase rather than pushing through.
- Grade visual load deliberately: distance before near, static before moving targets, quiet before busy environments.
- Coordinate return to learn and return to sport staging with the school team so the print demand and the movement demand do not both escalate in the same week.
- Persistent visual symptoms past the expected window is a referral, not a reason to extend rest.
Working alongside the OT
Your observations of gaze and posture under movement are data the OT does not otherwise get.
- Report the head velocity, the surface, and the environment in which performance changed.
- Ask which level is being treated first so your session grading matches the plan of care.
- Share carryover instructions with the family once, jointly, rather than as two separate home programs.
Refer, do not work around
- · Double vision, or an eye that turns or drifts
- · Symptoms provoked by ordinary head movement that are not settling
- · New or worsening visual complaints after a head injury
- · Balance loss that appears only in visually busy environments
- · Head tilt or a consistent head posture used to see
- · No full eye examination on record
Scope boundary. Assessment and treatment of visual performance deficits, including administration and scoring of the VPA™, remain within occupational therapy scope. What this supplement gives you is language for what you are seeing, decision rules for when to refer, and modifications you can make inside your own sessions so visual load stops confounding the skill you are actually treating.