THE BRAIN, BINOCULAR VISION, MOVEMENT, AND PAIN

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Binocular vision is the ability to use both eyes together to
create a single, cohesive image of the world. Optimal
binocular vision is vital for depth perception, spatial
awareness, postural control, and much more.

To understand it, imagine that your eyes are like two

cameras, each capturing a slightly different picture. When
you look at an object or take in an overall visual landscape,
each eye captures a slightly different perspective of the
same scene, and these two images are sent to the brain via
the optic nerves.

In the brain, particularly in the visual cortex, these inputs

are merged, or "fused," into one image.

While this sounds simple, it is INCREDIBLY complex, as

there are multiple factors involved as you’re about to see.

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• PROPER EYE ALIGNMENT: For binocular vision to function accurately, • CLEAR VISION IN BOTH EYES: Each eye must provide a sharp,
both eyes must be correctly aligned to focus on the same point in space. unobstructed image to ensure the brain can effectively merge the two.
Optimal alignment helps ensure: Conditions like cataracts, refractive errors, or corneal issues can disrupt
⚬ Fusion of Visual Images – The brain combines the images from each this process.
eye into a single perception.
• DEPTH PERCEPTION AND SPATIAL AWARENESS: Depth perception
⚬ Reduced Visual Strain – Misalignment can lead to double vision,
depends on the brain’s ability to analyze the slight differences between
headaches, or eye fatigue.
the images from each eye. This process, called stereopsis, is critical for:

• HEALTHY EYE MUSCULATURE: The six extraocular muscles in each eye ⚬ Judging distances.
must work together to enable precise movements. These muscles allow ⚬ Navigating environments.
for: ⚬ Performing tasks that require hand-eye coordination.
⚬ Smooth Pursuits – Tracking moving objects without losing focus.
• INTEGRATION WITH OTHER SENSORY SYSTEMS: Binocular vision
⚬ Saccades – Quick, precise shifts from one point of focus to another.
doesn’t function in isolation. It integrates with:
⚬ Convergence and Divergence – The ability to bring the eyes together
⚬ Proprioception – Senses body position and movement.
for near tasks and separate them for far tasks.
⚬ Vestibular System – Maintains balance and orientation.
• FUNCTIONAL NEURAL PATHWAYS: Effective communication between ⚬ Dorsal Column Pathways – Sense touch and pressure cues.
the eyes and the brain is crucial. Key components include:
⚬ Optic Nerves and Chiasm – Transmit visual signals from the eyes to • COGNITIVE AND ATTENTION CONTROL: The ability to focus attention
the brain. on visual tasks and process visual information efficiently is supported
by:
⚬ Visual Cortex – Integrates and processes the visual input.
⚬ Frontal Lobe Activity – For voluntary eye movement control.
⚬ Brainstem and Cerebellum – Manage alignment, focus, and motor
control of the eyes. ⚬ Parietal Lobe Activity – For spatial awareness and visual attention.

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Binocular visual dysfunction (BVD) occurs when the two eyes fail to
work together as a team. Instead of aligning smoothly and sending
coordinated signals to the brain, the eyes struggle to create a unified
image. This misalignment might not always be obvious, but its effects
can ripple through the entire body. Clients with BVD may experience
double vision, blurred vision, difficulty focusing, or even chronic pain
and postural imbalances.

Here’s the surprising part: the problem isn’t always with the eyes
themselves. Often, BVD stems from how the brain processes visual
input, coordinates eye movement, or adjusts to physical or
neurological stress. Think of BVD as a communication breakdown
between the brain and the eyes that can lead to compensatory
movement patterns, balance challenges, and even headaches or
dizziness.

For movement professionals, this is a critical concept. Visual

dysfunction often hides in plain sight, misunderstood as poor posture,
tight muscles, or a lack of coordination.

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As we’ve already mentioned, binocular vision dysfunction doesn’t just affect
sight—it can influence posture, movement, balance, and pain perception
through several mechanisms:

SENSORY MISMATCH AND NEUROLOGICAL OVERLOAD

• When the eyes are misaligned, the brain compensates by working
harder to merge inconsistent visual signals. This increased neural effort
can contribute to symptoms like:
o Chronic headaches or migraines.
o Neck and shoulder tension from prolonged postural adjustments.

POSTURAL ADAPTATIONS AND MUSCULOSKELETAL PAIN

• Clients with BVD often adopt compensatory postures to minimize visual
discomfort, such as forward head posture or asymmetric spinal
alignment.
• These adaptations strain muscles and joints, increasing the likelihood of
pain in the neck, shoulders, lower back, pelvis, and even the feet.

DISRUPTED PROPRIOCEPTION AND VESTIBULAR INTEGRATION

• BVD can interfere with spatial awareness and balance, causing altered
gait patterns and compensatory movement strategies that contribute to
chronic pain and poor athletic movement.

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While many things can disrupt binocular vision,
here are four well-known causes:
• NEUROLOGICAL ISSUES – Traumatic brain
injuries (TBIs) or stroke.
• NEURODEVELOPMENTAL PROBLEMS –
Delayed visual-motor integration.
• PHYSICAL STRAIN – Prolonged screen use
causing eye misalignment or fatigue.
• POSTURAL COMPENSATIONS – Neck, head, or
body misalignments affecting eye movement.

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ZHEALTHEDUCATION.COM
When it comes to understanding how vision impacts
movement, posture, and performance, you don’t need
a lab full of high-tech gadgets. A few simple in-office
assessments can reveal a wealth of information about
your client’s binocular vision. These tests help
uncover subtle misalignments, focusing challenges,
and coordination deficits.

The beauty of these assessments is their simplicity. In

just a few minutes, you can identify potential
dysfunctions in the visual system that may be holding
your clients back. Better yet, these tests give you a
roadmap for integrating more advanced assessments
and vision training approaches into your work,
allowing you to address the large and small issues
that affect a large percentage of clients.

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• Refer for a Standard Eye Exam

• Take a BVD History

• Uncover Test

• Pencil Push-Ups

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 PHYSICAL FINDINGS: READING:
• Aches in neck or shoulder and back pain • Tiredness when reading
• Moves over to left or right side when • Attention difficulties
walking • Loses concentration
• Knocks into shelves when walking down • Easily distracted in the classroom
the aisle • Reduced comprehension or reading fluency
• Binocular vision dysfunction • Tilts head • Skips over words or misses lines
• Falls too often
(BVD) often hides in plain sight, • Words seem to “float” or merge together
• Dizzy spells • Uses finger-pointing when reading
presenting as a collection of • Feeling faint
physical complaints, visual • Motion sickness
BINOCULAR VISION SYMPTOMS:
• Diplopia (double vision)
difficulties, reading struggles, and • Nausea
• Poor stereo vision or judges distances poorly
other issues that are easy to • Cheeks or sinus areas feel uncomfortable
• Difficulties with body-hand-eye coordination
misattribute to other problems. VISUAL SYMPTOMS: • Squints, tilts their head, or closes one eye to
• Vision appears blurry improve vision
• These symptoms can profoundly • Print or computer text is difficult to see
DRIVING SYMPTOMS:
clearly
affect quality of life and • Sees halos or glare during the night • Difficulty driving at night or in low light
performance, yet they’re often • Blurry vision in dim lighting, like in a • Avoids driving due to anxiety
• Loses confidence in accurately judging
missed or dismissed by restaurant or theater
distances
movement professionals. • Light sensitivity
• Eye strain at the office or during school ANXIETY SYMPTOMS:
• Frequent headaches or migraines • Heightened levels of anxiety
• To the right is a quick list from • Eyes hurt when they move • Panic attacks in crowded areas
optometrist.org of problems • Agoraphobia (the dislike of open or unfamiliar
associated with BVD. areas)

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 The uncover test is a simple, in-office tool used to evaluate
eye alignment and detect latent misalignments, known as
phorias, that are commonly associated with binocular vision
dysfunction (BVD). Here’s how to do it:

• Have your client use both eyes to stare at a visual target

10–20 feet away from them.

• Using an occluder, cover one eye to start the test.

• Pause for 5–10 seconds with the cover in place over the
first eye to allow time for the eye to “drift” either in
(esophoria) or out (exophoria).

• Quickly move the cover to the other eye while watching

for movement in the eye that was just uncovered. You are
looking for both the amount and direction of movement.

• Pause again for 5–10 seconds and then quickly move the
cover back to the first eye.

• Repeat this procedure in a swinging fashion, repeatedly

observing the eye that is being uncovered.

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Image from https://medschool.co/signs/uncover-test
Normal Findings
• When one eye is covered, the uncovered eye remains stationary,
indicating proper alignment and no latent misalignment.
• Upon uncovering, both eyes maintain alignment without visible
movement to readjust their position.
• Interpretation: The eyes are working together correctly, with no
significant phorias.

Abnormal Findings
• Movement in the Uncovered Eye
⚬ As an eye is uncovered, it shifts to align with the target.
⚬ This movement indicates a latent misalignment (phoria) that the
brain must compensate for during binocular vision.
• Types of Abnormal Movements Observed After Uncovering
⚬ Outward movement (Esophoria) – When uncovered, the eye drifts
outward to reacquire the target.
⚬ Inward movement (Exophoria) – When uncovered, the eye drifts
inward to reacquire the target.
⚬ Vertical movement (Hyperphoria or Hypophoria) – When
uncovered, the eye drifts up or down to reacquire the target.
• Interpretation: The brain is struggling to maintain alignment between
the eyes, suggesting potential BVD.

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The pencil push-up test evaluates a person’s ability to
converge their eyes on a near object, a key function of
binocular vision. It is commonly used to detect binocular
vision dysfunction, particularly convergence insufficiency.
Here’s how to do it:
• Tell the client to keep their head still.
• Hold the tip of a pencil or pen two feet in front of the
client’s face at nose level.
• Slowly move the tip of the pencil in toward the tip of
their nose until the client says “double,” indicating
they are now seeing two pencil tips instead of one.
• Measure the distance between the tip of the pencil and
the client’s nose.
• Repeat this process two more times and average the
measurements.
• Most clients should be able to avoid double vision until
the pencil tip reaches their nose.

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Normal Findings
• The eyes smoothly track the pencil as it moves closer to the nose and
maintain a single image (no double vision).
• The individual reports no discomfort or significant effort during the
task.
• The “break point”—the point where the image becomes double—
occurs very close to the nose, typically within 6–10 cm (2.5”–4”).
• Interpretation: The visual system is functioning properly, with no
significant signs of convergence dysfunction.

Abnormal Findings
• Difficulty Maintaining Focus – The eyes fail to stay aligned on the
pencil, and the image becomes double (diplopia) earlier than
expected.
• Eye Drift or Misalignment – One eye drifts outward or loses focus as
the pencil moves closer, indicating difficulty with convergence.
• Symptoms of Discomfort – The individual reports eye strain,
headaches, or excessive effort while performing the test.
• Delayed or Absent Recovery Point – Difficulty quickly realigning the
eyes to restore a single image after losing focus.
• Interpretation: Abnormal findings suggest convergence insufficiency
or other forms of binocular vision dysfunction.

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• The key to helping your clients with
BVD is to develop a personalized
training program based on these and
other assessments.

• Brain-based personalization of every

exercise and program is the
cornerstone of the Z-Health approach!

• Once you have a clear idea of what

their brain needs, you can choose from
an exercise menu like the one on the
next page.

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 Exercise Description How to Perform
Uses a string with multiple beads to train Focus on each bead sequentially while maintaining
Brock String Exercise
convergence and eye alignment. alignment as the beads are moved closer or farther away.

Improves convergence by training the eyes to focus Move a pencil toward the nose and back, keeping the
Pencil Push-Ups
on a moving near target. image single and clear.

Enhances the ability to track moving objects Follow a slow-moving object, like a penlight, with only the
Smooth Pursuits
smoothly. eyes, avoiding head movement.

Expands the visual field and improves coordination Focus on a central object while noticing objects or
Peripheral Awareness Training
between central and peripheral vision. movement in the periphery.

Strengthens the ability to quickly shift focus between Move the eyes rapidly between two stationary targets
Saccades
two targets. placed at different angles or distances.

Develops flexibility in changing focus between near Alternate between focusing on a close object and a distant
Near-Far Focusing
and far objects. one, establishing a clear image after every switch.

Improves focus and tracking skills using written or Trace letters or numbers in a pattern with the eyes,
Letter or Number Tracking
visual stimuli. avoiding head movement.

Combines head movement with eye alignment to Maintain fixation on a stationary target while turning or
Dynamic Visual Alignment Drills
improve gaze stabilization. tilting the head.
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