Sports vision practitioners have many opportunities to be involved with vision services for a sports team. A high percentage of professional and division I college and university sports teams in North America provide a vision screening program, and many also have an optometrist or ophthalmologist as a vision consultant. Many sports programs at all levels of competition use vision screening for their athletes, but many more do not have access to this service. A survey of professional, college, and university athletic programs and optometrists concluded that a significant unmet need exists for vision care services for athletes.
Many reports of vision screening results from athletes have been published. No single standardized sports vision screening has been used in any of the studies, and journal articles that discuss vision screening for athletes rarely specify a set of evaluation procedures with detailed protocols and normative data. , , The procedures chosen for sports vision screening of a team or athletic program typically result from considerations of time, location, vision task demands, and the value of the information acquired from the procedures. The result should be an efficient, high-yield battery of tests that identify vision problems that can interfere with peak sports performance and also allow comparison of athletes based on a profile of the vision skills assessed.
The results from a sports vision screening should be reported to the appropriate team personnel and the individual athletes. For those in the United States, the practitioner should ensure compliance with Health Insurance Portability and Accountability Act regulations. Many possible methods can be used to deliver this information, and the ability to communicate the findings and management recommendations effectively distinguishes the provider as an “expert.” Communication skills are at a premium if the objective is compliance with recommendations.
Developing a Sports Vision Screening
Most vision screenings are conducted at a location outside a sports vision practitioner’s office. A full sports vision evaluation on each athlete is usually not possible to conduct because of the limitations of time and location. The location of the screening may limit the use of some evaluation instruments because of the space available, control of lighting, availability of electricity, and portability of equipment. The amount of time available for the screening dictates the extent of testing feasible based on the number of athletes to be screened. The practitioner must also consider the available personnel to conduct the screening and determine how the athletes will proceed through the screening procedures for maximal efficiency.
Before the factors of time and location can be deliberated, the practitioner must identify the visual factors that potentially contribute to peak human performance so that these specific functions can be isolated and measured in the screening, if possible. The visual demands critical to success in sports can vary tremendously between different sports or positions. Chapter 2 provides an approach to the task analysis process essential for providing appropriate vision care to athletes. The evaluation procedures that are judged to yield the most relevant assessment of critical visual skills should be identified and contemplated for inclusion in the screening. The list of desirable procedures should then be reduced to the number of procedures that are feasible within the limitations of time and location. When determining which procedures should be selected, procedures that are the most suitable for sampling the vision skill areas identified as critical to performance are most commonly chosen.
In addition to the evaluation procedures chosen for the sports vision screening, the athlete’s history must be ascertained. The limitation of time is a factor with this part of the screening as well, and a questionnaire is commonly used to improve efficiency. The questionnaire should include some of the basic elements of a history for a comprehensive vision examination, including questions regarding main concerns, secondary vision concerns, and personal eye and medical history. The use of vision correction and eye protection is a crucial element to investigate in the athlete history questionnaire. Supplementary questions are listed in Chapter 4 that yield information concerning the athlete’s visual performance during the sport; these can be listed in the questionnaire. The ability to relate symptoms elicited on the questionnaire to the vision skills assessed in the screening is advantageous. The athlete history questionnaire should be verbally reviewed with the athlete, and thorough follow-up information should be obtained if time permits.
The decision of whether to include procedures for the evaluation of ocular health status is difficult. The range of procedures necessary to assess internal and external health is challenging to perform within the limitations of time and location. With the advent of new ocular health imaging technologies, documentation of elements of the athlete’s ocular health may be possible; however, these new technologies should be combined with a thorough ocular health assessment and not be used in isolation. Because an incomplete assessment of the elements of ocular health can be intolerably misleading, it is not recommended as part of a sports vision screening. A legal disclaimer stating the limitations of the screening and recommendation of routine comprehensive vision care should be included in the report materials provided to the team (see sample vision screening form in Appendix B).
As the practitioner gains experience with a variety of teams and sports, sport-specific screenings can be developed for use in subsequent screenings. The assessment areas and procedures used can be modified as needed on the basis of the results of further research and the practitioner’s own experience.
Conducting the Sports Vision Screening
Many aspects of a successful sports vision screening must be addressed before conducting the screening. Recording forms for the athlete data, a list of equipment and supplies to bring to the screening site, assessment protocols for each procedure, training of any ancillary staff who will be assisting in data collection, and development of the flow of athletes through the screening are all required elements.
Recording Forms
The recording forms for the screening should be developed in a manner that enhances the efficiency of the screening. Each assessment procedure should have a recording method that minimizes the amount of time needed to record each athlete’s results. Because a comparison of vision skills among athletes on the team is often performed, the screening form should also facilitate easy transfer to the comparison instrument that will be used. Ideally, athlete data would be directly entered on a computer spreadsheet for assessment at the conclusion of the screening, eliminating the need for paper forms. If a copy of the sports vision screening form will be provided to the team personnel and/or athlete, it will need to be designed in a manner that clearly communicates the results and recommendations as well as have a professional appearance.
Equipment and Supply List
For an off-site screening, the instrumentation selected for the screening should be portable and prepared for transportation. Some equipment will need to be adapted for use at the screening site. For example, the Senaptec Sensory Station ( www.senaptec.com ) has developed several visual performance assessments that can be conducted on a tablet computer in order to facilitate ease of screening outside a typical clinic location ( Fig. 5.1 ). Lighting can be a factor that should be prepared for. Any supplies and spare parts that may be needed for any instrument should be included in the list of items to bring, such as extra light bulbs, batteries, electric adaptors, extension cords, and power strips. Administrative supplies are usually needed, including clipboards, pens, staplers, masking tape, measuring tape, and name tags. The functioning of all equipment should be checked, and any batteries should be charged before departing for the screening.
Screening Protocols and Staff Training
Stringent assessment protocols should be established for each procedure used in a screening. If the goal is to compare vision skill performance among the team members, all team members must receive the same instructions and performance feedback. The instructions to the athletes before evaluation with each procedure should be standardized as much as possible to minimize the influence of variable instructions on performance. Modification of the instructions or screening protocols during the screening may be tempting; however, any modifications diminish the ability to compare athlete performance. The best way to avoid modifying assessment protocols is to master the procedures and fine-tune the instructions before conducting the screening. A trial run through the screening with a volunteer “athlete” is a good way to find any issues that need adjusting, and it should also provide an estimation of the time needed for each athlete to complete the screening.
The screening staff should all be thoroughly trained to administer the procedures with the established protocols. If the staff masters the procedure administration, the screening will be much more efficient. For some assessment procedures, a few practice trials are useful to familiarize the athlete with the performance demands prior to measurement. The number of practice trials should also be standardized for all athletes. The protocols should also include methods to motivate the athletes to demonstrate peak performance and ignite their competitive nature. On a procedure such as eye-hand coordination, the highest score achieved (so far) on that procedure by members of the team could be posted next to the apparatus to motivate each athlete to try to post the highest score for the team. Other than the use of the highest score on a particular procedure, each athlete should get minimal feedback on performance during the screening. For each procedure, the athlete should be told he or she is doing well and the results of the screening will be communicated at a later time. Under no circumstances should the athlete be told that he or she has failed any portion of the screening or that visual performance is below normal. The communication of visual performance results is highly sensitive and should be conducted in a manner that facilitates effective management. Therefore communication of screening results is typically reserved for the final report to the team personnel and the athlete.
The instructions to each athlete for each procedure should educate them about the nature of the vision skill being evaluated. The relevance of the vision skill to specific task demands of the sport should be explained to the athlete to help encourage proper motivation during the screening. The better the athlete is motivated to perform on each procedure, the more accurate the measurement of ability becomes. The staff conducting the screening should also be trained to elicit any additional case history information as the athlete proceeds through the screening.
The Flow of the Screening
How the athletes will flow through the screening should be determined in advance. One common setup is to have a number of stations that the athlete moves through where specific assessment procedures are conducted. Ideally, each station should take the athlete the same amount of time to complete so that backup does not occur at certain stations. This ideal situation is not always possible when one procedure takes significantly more time to administer than other procedures in the screening.
Consideration should be given to the importance of the sequence of the screening because altering the sequence of the screening may be tempting for some athletes if a considerable backup is present at particular stations. However, in general, every athlete should go through the screening sequence identically to facilitate comparison of athlete performance. For example, if one athlete performed a visual motor speed assessment at the beginning of the screening and another performed it at the end of the screening, the results may be tainted by the difference in screening sequence. Although this is an important consideration, it is also recognized that assessment sequence may not significantly alter performance results.
The station-to-station approach can be efficient because the staff have mastered the administration of the procedures at their particular station ( Figs. 5.2 and 5.3 ). However, if a group of sports vision practitioners is conducting the screening, each practitioner may take individual athletes through every station of the screening. By having a single practitioner conduct all the procedures, the practitioner may develop more insight into the performance and issues with each individual athlete. The additional insight gained by the practitioner conducting all the screening procedures may be translated into more effective recommendations for that athlete.
No matter which method of screening athletes is chosen, each athlete should proceed through the screening expeditiously. For the team personnel, the time available as a team is extremely valuable. The impression that the team’s time is being wasted sitting or standing around during a screening should be avoided. A meeting with the team personnel before the screening is highly recommended to discuss potential scheduling schemes for the team. A reasonable flow of athletes through the screening can be scheduled in coordination with other team training activities. Demonstrating an understanding of the needs of the team and creativity in finding mutually beneficial solutions are greatly appreciated by team personnel.
A meeting time in advance of the screening also affords an excellent opportunity to preview the screening area that will be used. This preview should provide valuable information for designing the floor plan for the screening stations and developing the most effective flow for the screening. Team personnel should also complete the sports vision screening because this will impart useful firsthand experience with the visual skills assessed. The consultation with the team personnel to discuss the screening results is more effective if the team personnel have firsthand knowledge of the vision skills being discussed.
An additional consideration when developing a sports vision screening is the need for supplementary testing. A vision problem may be detected in an athlete during the screening that requires further testing. For example, a cover test may be performed when an athlete has significantly reduced stereopsis in order to determine a possible cause of the reduced stereopsis. The practitioner will need to decide what additional testing may be needed on-site and bring the necessary equipment to conduct that testing. Conversely, the practitioner may choose to simply refer any athletes for follow-up care when vision problems are identified during the course of a screening.
Generating Reports for Sports Vision Screenings and Sports Vision Evaluations
Reporting the results of a sports vision screening or sports vision evaluation is absolutely critical for the success of any sports vision program. The report should be communicated to the team personnel and/or individual athletes in a timely manner, such as within 2 weeks of the screening or evaluation. Ideally, a report would be generated immediately at the conclusion of the evaluation. Keep in mind that the interested parties need to know the following five W ’s :
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What needs to be done?
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When does it need to be done?
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Who should carry out the recommendations?
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Where does it need to be done?
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Why does it need to be done?
Many methods can be used to construct a report letter for a vision evaluation and no single method is superior. When reporting the results of a sports vision assessment, the inclusion of a vision skill performance profile is recommended to communicate the relative strengths and potential disadvantages demonstrated by the athlete. I prefer to describe subpar performance as an “opportunity to improve” rather than a weakness. The development of a performance profile is easier when conducting a team assessment because the peer group data are available for direct comparison. When an individual assessment has been performed on an athlete, the practitioner must use available normative data or compare performance to other athletes previously evaluated. See Appendix C for a sample sports vision evaluation summary letter for an individual athlete.
Many computer spreadsheet software programs are available that provide a simple method for comparing vision skill performance by athletes on a team. The data from each athlete can be entered on a spreadsheet when numeric results are present, allowing calculation of performance averages and standard deviations for each procedure. Most data spreadsheet programs have functions for making many statistical calculations. The practitioner must appraise each performance average and standard deviation to determine if the values are appropriate for comparison and recommendations. For example, if a team has demonstrated an unusually high level of visual acuity and 20/20 (6/6) is more than 1 standard deviation below average performance, what recommendations will be made for an athlete who achieved “only” 20/20 visual acuity? Team data can also be compared with available normative data to help determine the validity of the results.
Many possible methods can be used to present visual performance profile information to the team personnel and athletes. The presentation should be easy to interpret by the intended audience. A simple bar graph can be effective for showing relative strengths and weaknesses. The average performance on each skill should be apparent from each athlete’s profile, and a benchmark scale illustrating relative performance should also be readily apparent. When appropriate, a scale of 1–5 for the vertical axis of a bar graph can be used, with 3 always representing the performance average for the team on each procedure (see Appendix D). The standard deviation for performance on each procedure is represented by each whole number step on the graph. Specifically, the average is represented by number 3 on the y -axis, and 1 standard deviation above and below the average is represented by numbers 4 and 2, respectively.
To perform a statistical analysis of the visual skill performance of an individual athlete compared with team data or normative data in the context of the scale from 1 to 5, two simple calculations can be performed. If a higher numeric value indicates better performance, such as a score on a Go/No Go assessment, the following calculation is applied:
[(Athletescore−Averagescore)/Standarddeviation]+3
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