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Financial Disclosures

Sports Vision 101 -C. Light Technologies • Clinical Research Consultant, NIH SBIR

Jacqueline Theis, OD, FAAO COA OptoWest – Sacramento April 15, 2018

Who is an Athlete? Outline Who defines themselves as an athlete versus who we consider an athlete can vastly differ • Lets Talk - How sports can be a practice builder? – Epidemiology of athletes What defines a ? • Physical strength – Role of athletics for kids • Speed • Endurance • What is Sports Vision?

– The Basics – Primary Care How proficient must a person be to • Refractive considerations be considered an athlete? • Ocular health in athletics – Advanced – Tertiary Care • Sports performance enhancement

Percentage of population engaged in sports and exercise on an average day, by state, 2009-2015

Epidemiology of Athletes and your Patients

Woods RA. Sports and Exercise. US Bureau of Labor Statistics – American Time use Survey. May 2017 Report. https://www.bls.gov/spotlight/2017/sports-and-exercise/home.htm

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Percentage of population engaged in sports and exercise on an average day, by sex 2003-2015 Percentage of population engaged in sports and exercise on an average day, by educational attainment, 2003-2008 and 2009-2015

Woods RA. Sports and Exercise. US Bureau of Labor Statistics – American Time use Survey. May 2017 Report. Woods RA. Sports and Exercise. US Bureau of Labor Statistics – American Time use Survey. May 2017 Report. https://www.bls.gov/spotlight/2017/sports-and-exercise/home.htm https://www.bls.gov/spotlight/2017/sports-and-exercise/home.htm

Walking Percent distribution by age Weight lifting group of people who Using cardiovascular equipment Yoga Running engaged in sports and Swimming, surfing, water skiing exercise on an average day, Walking by specific activity, 2009-2015 Percentage of people Aerobics Golfing aged 15 and older Using cardiovascular equipment Cycling who engaged in Yoga Hiking sports and exercise Aerobics Golfing on an average day, by Soccer Racquet sports specific activity, , 2009-2015 Cycling Dancing Swimming, surfing, water skiing Bowling Racquet sports Hiking Weight lifting Volletball Running Rollerblading Dancing Skiing, ice skating, snowboarding Equestrian sports Baseball, softball Martial arts Woods RA. Sports and Exercise. US Soccer Bureau of Labor Statistics – Football Gymnastics American Time use Survey. May 2017 Report. Wrestling Basketball Woods RA. Sports and Exercise. US Bureau of Labor Statistics – https://www.bls.gov/spotlight/ American Time use Survey. May 2017 Report. 0% 5% 10% 15% 20% 25% 30% 35% 2017/sports-and-exercise/ 0% 20% 40% 60% 80% 100% https://www.bls.gov/spotlight/2017/sports-and-exercise/ home.htm home.htm

Percentage of people who engaged in sports and exercise on a given day, by hour of day when exercising, 2009-2015 Sports Statistics – What about Kids?

• A lot of people play sports.

30% • 2011- Sports and Fitness Industry

Association (SFIA) estimated 21.5 million

20% kids 6-17yo played team sports

10%

0% 4:00AM 8:00AM 12:00PM 4:00PM 8:00PM 12:00PM

Woods RA. Sports and Exercise. US Bureau of Labor Statistics – American Time use Survey. May 2017 Report. https://www.bls.gov/spotlight/2017/sports-and-exercise/home.htm

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Kelley B, Carchia C. “Hey, Data data – swing!” ESPN The Mag. Jul 2013 Kelley B, Carchia C. “Hey, Data data – swing!” ESPN The Mag. Jul 2013

Downside of Sports • Injury! – #1 Fear of Sports Parents • CDC: 2.6 million kids under 20 years old are treated in the ER for sports and recreation-related injuries each year • CDC: From 2001-2009, ER visits for TBIs rose from 19% to 62% – Football concussions among 10-14 year olds doubled from 4,138 (2000) to 10,759 (2010)

Centers for Disease Control and Prevention. Protect the Ones you Love – Child Injuries are Preventable: Sports Safety. www.cdc.gov/safechild/sports_injuries/index.html Accessed November 28, 2016

Centers for Disease Control and Prevention. Nonfatal Traumatic Brain Injuries Related to Sports and Recreation Activities Among Persons Aged < 19 Years – United States 2001-2009. MMWR 2011: 60(39):1337-1342 Kelley B, Carchia C. “Hey, Data data – swing!” ESPN The Mag. Jul 2013

What is Sports Vision? Vision in Athletes

What we know • Athletes have better visual abilities than non athletes • Better athletes have better visual abilities than poorer athletes • Visual abilities are trainable

• Visual training is transferable to performance – So we say

Stone CD, Arterburn MR, Stern NS J am Optom Assoc - Vision and sports: a review of the literature - 1982: aug 53(8):627-33 Christenson GN, Winkelstein AM - Visual skills of athletes versus nonathletes: development of a sports vision testing battery. J Am Optom Assoc. 1988, 59 (9):666-75

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Relevant Visual Abilities

• Larger extent of visual fields • Larger fields of recognition • Larger motion perception fields (peripheral awareness) • Lower amounts of heterophoria THE SPORTS VISION EXAM • More consistent simultaneous vision • More accurate depth perception • Better dynamic visual acuity • Better ocular motilities ( facility, saccades, NPC) • Visual reaction time

Stone CD, Arterburn MR, Stern NS J am Optom Assoc - Vision and sports: a review of the literature - 1982: aug 53(8):627-33 Christenson GN, Winkelstein AM - Visual skills of athletes versus nonathletes: development of a sports vision testing battery. J Am Optom Assoc. 1988, 59 (9):666-75

Patient History - Sport Patient History – Ocular Symptoms • Blurry vision • Sport(s) • Double Vision • Level • Difficulty following/tracking a ball/moving objects • Position(s) • “Gaps” in their vision • Frequency/Season played? • Difficulty with timing • What visual correction is • Inconsistent play - Too early/too late to hit or catch the ball currently worn for sports? • Difficulty changing focus from different distances • When do they play their • Light Sensitivity sport? • Difficulty playing at night • Where they play? • Easily distracted from visual target • Difficulty concentrating in visually crowded areas • Difficulty judging distances/depth perception • Headaches • Difficulties/eyestrain/fatigue with close work (CISS)

You play WHAT Sport?!? You play WHAT Sport?!? • Dare I say… Google it !? • Ask enough questions to ask the visual demands of the sport – Is the athlete still (static) or moving (dynamic)? – Is the object/target stationary or moving? – What type of environment/contrast demands? • Weather, lighting, shadows, glare, background, type of object (ball, target, etc) – Timing demands on the • Baseball batter (rapid saccades/pursuits) vs. Golfing (fixation) – Distance of targets – Direction of targets – Cognitive, Cardiovascular, Balance demands – Visual Attention Demands

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Case Example – Bob the Billiards Guy 12pd Vertical prism ground in

Pupil Centers Bob the Billiards Guy • S/p ischemic stroke in right occipital lobe and midbrain – Left – Right CNIII Palsy

Fresnel Prism

Visual Acuity

• Static Visual Acuity – At Least 20/15 The Sports Vision Examination – Snellen vs. Landolt C – Glare Acuity

Zimmerman AB, Lust KL, Bullimore MA. Visual Acuity and Contrast Sensitivity Testing for Sports Vision. & Contact . 2011;37:153-159.

Contrast Sensitivity E Visual Acuity • Tests – Vistech • Dynamic Visual Acuity – Mentor BVAT – VOR/Horizontal Sweeps – Vector Vision 1000 – Rotating Chart – Pelli-Robson – M&S Sports Performance – MARS – M&S Sports Performance

E • Can be reduced by higher-order aberrations from CLs, E refractive surgery, as well as retinal conditions

Erickson G. Sports Vision: Vision Care for the Enhancement of Sports Performance. Butterworth-Heineman. Philadelphia. 2007. Zimmerman AB, Lust KL, Bullimore MA. Visual Acuity and Contrast Sensitivity Testing for Sports Vision. Eye & Contact Lens. 2011;37:153-159.

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Stereo Acuity Stereo Acuity • Where is it in space? • Judgment of distance is based on our perception of Monocular Cues Binocular Cues depth • Pictorial • Retinal Disparity • Tests – Size, linear perspective, • Convergence – Lateral Disparity vs. Random Dot texture, interposition, – Near vs. Distance clarity, lighting, shadow – Howard Dolman • Motion Parallax – Brock String • – Fields of Gaze • Angular declination – Suppression

Prescribing for Different Refractive Correction Guidelines Distances/That Darn Presbyope! • -0.25D or more • Most dynamic ball sports • Target • Hyperopia +1.00D or more – SVD – Shotgun • • • 0.50D or more Golf SVD – Small, low set segment – Rifle • 0.50D or more – Short corridor, narrow • SVD – mild overplus PAL with lower set seg +0.50/+0.75 • Best time to experiment is off season height • Telescopic sight • Scuba Divers • Sports Performance Prescription may be – Pistol different from Habitual Rx – MF CL or insert • Pinhole • Goggles – The benefits of over-minusing • BF – Executive/FT40 – Rx or insert Erickson G. Sports Vision: Vision Care for the Enhancement of Sports Performance. Erickson G. Sports Vision: Vision Care for the Enhancement of Sports Performance. Butterworth-Heineman. Philadelphia. 2007. Butterworth-Heineman. Philadelphia. 2007.

Contact Lenses – High Performance Fitting Contact Lenses – High Performance Fitting

Daily Disposable

Larger Soft Diameter Factors to Consider Tighter Base Curve Modality Gas Fit Environment Permeable

Hard Ortho-K Lens UV Time of Toric? Season Terrain Stability Protection Day Scleral Lenses • Unstable lenses can degrade CS even when VA is normal

Zimmerman AB, Lust KL, Bullimore MA. Visual Acuity and Contrast Sensitivity Testing for Zimmerman AB, Lust KL, Bullimore MA. Visual Acuity and Contrast Sensitivity Testing for Sports Vision. Eye & Contact Lens. 2011;37:153-159. Sports Vision. Eye & Contact Lens. 2011;37:153-159.

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UV Exposure Refractive Surgery Case • UV exposure increases 8-10% for every 1000ft gained in Management altitude • Athletes experience intense UV exposure • Who is a candidate? – Reflection of UV radiation exposure from the ground • LASIK vs. PRK • 60-100% off snow • 10-15% off sand • 2-3% off grass • CONS • <10% water – Trauma – Surgical/postop complications – Other vision issues – glare, halos, Rx http://www.globalhealingcenter.com/natural-health/vitamin-d/ regression Rigel DS, Rigel EG, Rigel AC. Effects of altitude and latitude on ambient UVB radiation. J Am Acad Dermatol. 1999;40(1):114-6 Jinna S, Adams BB. Ultraviolet radiation and the athlete: risk, sun safety, and barriers to implementation of Schwartz B, Hagelbaum B. Refractive Surgery for Active Patients: Weighing the protective strategies. Sports Med. 2013;43(7):531-537 Pros and Cons. Phys Sports Med. 1999. 26(10):72-86

Risk of Eye Injury and Sport Sports-Related Ocular Injury Moderate Risk Sports High Risk Sports • Approx. 30,000 individuals Involve small, high speed dense High-speed ball/puck, use of a in close proximity to present to the ER annually athletes (balls, fingers) bat/stick, close aggressive with sports-related eye • Air Rifle physical body contact with injuries collisions • • 90% are preventable with • Badminton • Football protective eyewear • Baseball/Softball • Archery/Darts • Basketball • 3-7% of all ocular injuries • Rugby • Boxing are due to spectacle- • • Soccer/ related ocular trauma • Fencing • Waterpolo • • DOCUMENT in your • CHART Image from https://www.progearvisionlab.com/eye-injury/ • Haring RS, Sheffield ID, Canner JK, Schnieder EB. Epidemiology of Sports-Related Eye Injuries in the • Squash/racquetball . JAMA Ophthalmol. 2016 Nov 3. (Epub ahead of print) • Tennis Image from http://www.see-eci.com/blog/eye-care-institute/sports-eye-protection/ Hoskin AK, Philip S, Dain SJ, Mackey DA. Spectacle-related eye injuries spectacle impact performance Dain SJ. Sports eyewear protective standards. Clin Exp Optom. 2016;99(1):4-23 and . Clin Exp Optom. 2015;98(3):203-9.

Protective Eyewear Protective Eyewear • Fractured spectacles convert a blunt Individual Risk Factors Eyewear Design trauma to a penetrating eye • Monocular • Wrap-around style injury • Previous Eye Surgery – Eliminate hinge • Legal liability exists for the • Previous Eye Injury • Changeable lenses prescriber of spectacles for • Thin • Goggles sports • Elderly – Vents participants • ARC reduces impact resistance of lenses

Image from http://www.luckygunner.com/labs/eye-protection-shooting-glasses-review/ Hoskin AK, Philip S, Dain SJ, Mackey DA. Spectacle-related eye injuries, spectacle-impact Hoskin AK, Philip S, Dain SJ, Mackey DA. Spectacle-related eye injuries, spectacle-impact performance and eye protection. Clin Exp Optom 2015: 98:203-209 performance and eye protection. Clin Exp Optom 2015: 98:203-209 Dain SJ. Sports eyewear protective standards. Clin Exp Optom. 2016: 99:4-23 Dain SJ. Sports eyewear protective standards. Clin Exp Optom. 2016: 99:4-23

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Protective Eyewear Standards • ANSI • NOCSAE • ASTM – 072-04m13 – Baseball, Softball – F803 – Basketball, baseball, racquet sports – 024-11m13 – Baseball/Softball (Racquetball, squash, Catchers tennis, badminton), field – 045-09,13, 041-11m12 – Lacrosse hockey, women’s lacrosse – F910 – helmet shield, – 035-11m12 – Ice Hockey youth baseball batters/ – ND087-12m14 – Martial arts TINTS runners – F513, F1587 – Ice hockey – F1776 – paintball – F2879 - airsoft – F659 – Skiing and snowboarding goggles/ shields – F2713 – field hockey http:// www.sunglassconnection.com.au /files/image/RIP%20CURL/ www.cdc.gov/headsup/helmets/index.html lenses_techpage.jpg

Glare Yellow Filters • Difficulty seeing in bright light – Direct Glare – from the sun • Yellow color cuts blue light – Reflected Glare – from surfaces • High luminous transmittance ~550nm (water, sand, snow, pavement) • Kohmura Y, Murakami S, Aoki K. Effect of Yellow-Tinted Lenses on Visual Attributes related to Sports Activities. J • Visual perception created when Hum Kinet. 2013;36:27-36 external light becomes scattered – N=24 students (11 females, 13 males, ~21yo) inside the eye – Compared colorless, light yellow, dark yellow, light gray, dark gray lenses on visual metrics (contrast sensitivity, dynamic VA, • Wavelength of light is inversely depth perception, hand-eye coordination, static VA, and low- related to light scattering intensity contrast VA) – Results – Blue light (short wavelength) scatters • In sports that require quick hand-eye coordination, Dark Gray lenses more than red light (long had adverse effects wavelength) • Contrast sensitivity was higher for Clear, Light Yellow and Light Gray – Low luminance transmittance may affect contrast sensitivity! – Blue light contributes more to glare, • Daytime + Glare – no difference in low-contrast acuity for all lenses

Images from reducing contrast and visual acuity • Evening + Glare – low-contrast acuity higher for Clear and Light http://motherboard140.rssing.com/chan-6898904/all_p23.html Yellow lenses http://www.sunglasshut.com/wcsstore/SGH/experiences/US/ evergreen/sports/images/L1c.jpg • LIGHT YELLOW! Mahjoob M, Heydarian S, Koochi S. Effect of yellow filter on visual acuity and contrast sensitivity under glare condition among different age groups. Int Ophthalmol. 2016;36:509-14

Nike Maxsight Lenses – No More Tinted Contact Lenses • Performance tinted contact lenses – Grey-Green Biosport • Outdoor activities – train running, mountain biking, water Acuvue 1 Day Define sports, golf – Amber • High-speed ball sports – soccer, tennis, baseball • Improve low-contrast VA more than eye-black grease • Filtering out short-wavelength light (amber) can reduce chromatic aberration which can increase visual acuity • Can improve contrast sensitivity and speed of visual recovery in bright sunlight http://www.orionvisiongroup.com/biosport/

Horn FC, Erickson GB, Karben B, Moore B. Comparison of low-contrast visual acuity between eye black and Maxsight tinted contact lenses. Eye & Contact Lens. 2011;37:147-152 Porisch E. Football players’ contrast sensitivity comparison when wearing amber sport-tinted or clear contact lenses. . 2007;78:232-235 Erickson GB, Horn FC, Barney T, et al. Visual performance with sport-tinted contact lenses in natural Watanabe K, Kaido M, Ishida R, et al. The effect of soft ontact lens wear on functional visual acuity and higher- sunlight. Optom Vis Svi. 2009:85:509-516 order aberrations. Contact Lens & Anterior Eye. 2014;37:203-208

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Color Lighting Weather Sport Pros Cons Pink/Rose Low - Med Partly cloudy Cycling Heightens contrast Color imbalances Overcast Fishing Dusk/Dawn Hunting Shooting Snow sports Water sports Red Med-Bright éColor definition Color Imbalances Light Amber Bright Overcast Cycling éContrast Color imbalances Copper Partly Cloud Hunting/Shooting éVA • Ocular Posture Orange Sunny Snow Sports Blocks blue light Fog Basketball – Racquetball • Primary Gaze Tennis – Distance/Near Dark Amber Very Bright Sunny Blue Baseball éContrast Color imbalances Brown Skies Cycling éVA • Nine Fields of Gaze Fishing Blocks blue light Golf – Distance/Near Hunting Snow sports – Water sports Gray All outdoor sports Reduces overall in bright light brightness Normal color vision Green Low-Bright Sunny Golf Preserves colors Baseball Mild éContrast êBrightness Easier on grass Image from http://www.convergenceinsufficiency.net/ detail.asp?id=18&pid=13 Blue/Purple Low Fog Snow Sports êGlare Overcast Football Enhances details Tennis (bumps/mogels) Soccer

Binocular Vision Binocular Vision

• Oculomotor Function • Eye Movements – – Fixation • Ranges – Saccades • Facility – Pursuits – Near-Far vs. Flippers – Integration – Accommodation • DEM • Amplitude • King Devick • Facility • Visagraph – Near-far vs. Flippers • RightEye

Image from https://en.wikipedia.org/wiki/ Prism_fusion_range

Ocular Health – In your Exam Lane Eye-Hand-Foot Dominance – Performance Perspective • Crossed Dominance • Anterior Segment • Uncrossed – Ocular Surface Dominance • Dry Eye, , – oh my! – Contact-lens overwear discussions • Risk of corneal infection and impact on play – Lens Anomalies – ? • Posterior Segment – Macular anomalies – ERM?

Image from https://wawanghunting.com/2016/10/19/determining-your- dominant-eye-2/

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First Aid Tips for Eye Injuries on the Sideline Cuts, punctures, foreign objects in the eye Blows to the Eye Ocular Health on the Sideline • DO NOT wash out the eye • Seek medical attention if • DO NOT try to remove the – -Educate others foreign object – Pain • Seek immediate medical – Cannot open the lids attention -Know your trauma – Eyeball looks different than • Try to avoid rubbing the eye the other eye – Blurry vision Chemical Burns • Immediately flush the eye with cool water for at least 15 minutes, THEN seek immediate medical attention

Conjunctival Laceration vs. Corneal Abrasion Subconjunctival Hemorrhage

Sx:Mild Pain, red eye, foreign body Sx: Painless Sx: sensation *Self Resolves • Sharp pain *Blood in tears (hemolacria) Can return to play • *Refer for antibiotics • Foreign Body Sensation/Discomfort Cannot return to play with Blinking • Tearing • History of scratching or hitting the eye Signs: • Epithelial defect stains with Fluorescein Treatment: http://www.consultant360.com/article/traumatic- • Topical antibiotic QID x 5-7 days corneal-abrasion • Bandage contact lens • Cant return to play until re- epithelializes http://www.reviewofoptometry.com/roexams/109005/img6.jpg https://goodvisionohio.files.wordpress.com/2012/11/ subconjunctival_haemorrhage.jpg?w=640

Traumatic Iritis Traumatic Sx • Pain Sx: • Blurred vision • Dull, aching/throbbing pain – usually occurs at time of injury • Photophobia – Decreasing vision over time = • Onset of sx within 3 days of rebleed or continuous bleed trauma • Hx of Blunt Trauma • Perilimbal conjunctival injection Signs *Pain in the traumatized eye when • Blood in the anterior chamber light enters either eye • 100% = 8 ball Hyphema • Immediate Referral to OD/OPH *NO ANTICOAGULANTS - NO ASPIRIN!!

Images from http://www.slideshare.net/bcooper876/anterior- pole-dr-scott-burdette-45156689 http://www.iritis.org/wp-content/uploads/2014/04/ https://s-media-cache-ak0.pinimg.com/236x/ iritis_eye.jpg 14/42/68/1442683a7e6b2266a309c9cf8f473c6b.jpg https://dailyem.wordpress.com/2013/12/13/hyphema-quick- review/

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Iridodialysis/Cyclodialysis Traumatic Asymptomatic

• Monocular double vision, glare, • - torn from scleral • Usually Asymptomatic photophobia spur • Can take 10-20 years to At Risk for Glaucoma • Cyclodialysis - torn from develop scleral spur • Hx of hyphema or orbital trauma • Lifelong suspicion

http://eyeworld.org/article-cataract-surgery-in-the-setting-of- http://melodom.blogspot.com/2013/06/glaucoma-etc.html iris-defects http://www.oculist.net/downaton502/prof/ebook/duanes/pages/ v6/ch024/014f.html

Orbital Blowout Fracture Orbital Blowout Fracture Continued...

Sx: • Pain on eye movement Mechanism – Orbital floor - vertical eye movement • Force causes backward – Medial Wall - Lateral eye movement displacement of the eyeball • edema • Leads to increased intraorbital • Binocular Double Vision pressure • Crepitus after nose blowing • Leads to fracture in weakest • orbital wall (floor/nasal) DDx • Orbital Edema and Hemorrhage w/o fracture – Limitation of ocular movement, periorbital swelling, ecchymosis resolve 7-10 days • Cranial Nerve Palsy http://www.firstaidevents.com/articles/maxillofacial-trauma http://www.rcemlearning.co.uk/references/zygomatic-and- https://encrypted-tbn0.gstatic.com/images? nasal-injury/ q=tbn:ANd9GcSfB7A3hK1GHAX9XWco9exN-7pJBLyeDp5vv- opK9GF-wL8ghhs9g

Proptosis vs Enophthalmos Retinal Tear/

Sx: • Flashes of Light • • Proptosis () • Missing Side Vision – Eye coming out of the – ie Traumatic Retrobulbar Hemorrhage • Enophthalmos – Eye sunken into the globe – ie Orbital Blowout Fracture

http://scielo.isciii.es/scielo.php? pid=S1130-05582008000600007&script=sci_arttext&tlng=en

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Post Traumatic Reduced Vision (Often Painless)

Sports Vision Performance The next step in assessment and enhancement

Sports Performance Vision Orthoptic Training Training • Remediation vs. Enhancement 1. Remediate visual inefficiencies • Accommodation 2. Enhance visual skills critical for sport • Vergence performance 3. Enhance of visual processing skills for • Eye Movements increased visual processing speed 4. Enhance visuomotor proficiency 5. Enhance critical cognitive functions for visual decision making

Visual Processing Skills The Periphery

• Visual Processing Speed • Peripheral visual field – Motor Response Time • Peripheral awareness – Visual-Motor Reaction Time – Speed of Recognition • Peripheral hand-eye response speed • Visual Anticipation • Field Dependence/Independence – Visual Closure

Wayne Saccadic Fixator

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JND Training Visual Perceptual Training

• Spatial Localization • Acuity – Dynamic vs. Static – Accuracy/Speed of Depth Perception • Contrast Sensitivity • Speed of Recognition • Visual-Motor Response – Proactive – Reactive • Peripheral Vision • Anticipation • Visualization

Image from https://www.exploratorium.edu/ baseball/putting_3.html

Multi-Sensory Loading

• Balance • Auditory • Proprioception • Cognition Questions???

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