To Paul Ramsey, Berkeley grad (’86) and a 63-year-old right fielder in the Men’s Senior Baseball League (MSBL), the problem wasn’t fastballs, though. It was changeups and knuckleballs, any pitch he had to watch carefully and adjust his swing to. When he returned to the sport after a five-year hiatus in his late 50s it was embarrassing. “I was swinging half-a-second early,” Ramsey says. “I’d always been a strong hitter, but I was striking out again and again. I couldn’t time my swing with what I thought I was seeing.”
In addition to missing easy pitches, Ramsey also started losing track of golf balls he hit off the tee. “I’d have to ask the guys I was playing with where my ball went,” he says. Something was up with his vision, he remembers thinking, so he turned to the web, which eventually led him to the Sports Vision and Concussion Clinic. Shumaker told Ramsey he could help.
The clinic was established in 2015 to investigate post-concussion eye movement dysfunction, but it now sees a diverse array of patients, including older amateurs like Ramsey, professional athletes from the Bay Area and beyond, Cal’s college athletes—some suffering from concussions and others not—and more and more players from other schools such as Saint Mary’s College. The clinic also sees patients referred in from the student health center and local physicians, including neurologists and sports medicine physicians at UCSF, Benioff Children’s Hospital, and Stanford.
The clinic’s patient base isn’t limited to athletes, however. “I think of it as a performance vision clinic, not just a sports clinic,” says Shumaker. It’s his conviction that most of us could use a little visual tuning to unlock our full potential, saying “A high-functioning visual system is key to so much of what we do, and inefficiencies and deficits can hold people back in all different areas of life.”
Take Rachel Beardsley, a former high school softball player. She’d never loved math, but in her sophomore year of high school she hit geometry like a brick wall. Not only did the otherwise good student have a hard time reaching correct answers in geometry class, she couldn’t understand what the questions even meant. It was a measure of Beardsley’s determination that she spent hours each night being tutored by her math-teacher mom, but it was to little avail. “I was failing pretty much every test and my teacher thought maybe I should see if there was something else going on,” Beardsley says.
And although she played softball for almost a decade, including her first two years of high school, Beardsley had an astonishingly hard time hitting a softball. “I just couldn’t tell where the ball was going to be,” she says.
She was referred to the clinic by human performance researcher Greg Appelbaum, PhD, currently at UC San Diego. “It turns out I’ve got a visual processing disorder, which makes it really hard to do geometry,” says Beardsley. “We didn’t do a thing to try to teach Rachel geometry concepts,” says Shumaker, “but math, including geometry, is based on spatial concepts. And inefficiencies in the ways the eyes work—either with the basic stuff, how the eyes align, team together, focus, converge, or how you process visual information—these can impact math concept acquisition and performance. And the exercises we did
with her increase visual efficiency and visual processing, which makes it easier to grasp concepts in math. The neurological underpinnings responsible for processing spatial information were improved by the exercises.”
After four months visiting the clinic once a week, not only did Beardsley shift the trajectory of her geometry class into a different plane (she got 90% on her final and ended the class with an A-), but she also adjusted her athletic career, switching to water polo for the second two years of high school, averaging two points per game and being named offensive MVP in her senior year.
The link between good binocular vision and both sports and academics are key for many of the student athletes that visit the clinic, says Christina Wilmer, OD, clinical professor and associate dean for clinical affairs at the school. “We want all our athletes to do well academically and in their sport. Having high-functioning visual systems really does relate to both,” she says.
Traumatic Brain Injury Symptoms
Historian and recreational cyclist Thomas Dublin was happily descending a steep winding road out of the Oakland Hills when the next thing he knew he was in Highland Hospital’s ER. He’d passed out and crashed, it seems, and fractured his skull in three places. Luckily, he was quickly discovered by a passerby and rushed by ambulance to the hospital. After the accident, though, he had balance problems and was unable to drive. “I was also exhausted,” he says, “sleeping 13 to 15 hours a day.”
Inability to work was perhaps the most disabling of Dublin’s symptoms. At 74, he had retired years earlier from his professorship at State University of New York at Binghamton, but he still engaged in academic projects that required hours of daily reading, research, and writing, much of it on his computer. “After my bike accident, I could only spend a short time looking at a screen or a book before feeling exhausted.”
Dublin’s daughter, a physician, consulted a neurologist she knew at UCSF who recommended that Dublin get a vision workup at the Berkeley Sports Vision and Concussion Clinic because of its experience with the visual ramifications of concussion.
“Whether we’re working with a professional athlete in their prime who just wants to increase reaction time and improve performance by a little bit, or if it’s someone who’s had a concussion and can no longer drive, we start the same way,” says Shumaker. “We ask, ‘What are your goals? What are you hoping to get out of this treatment?’”
Dublin’s goals were clear: he wanted to get his pre-concussion levels of energy back, to be able to work at his computer again without so quickly becoming exhausted, and to be able to bicycle and drive again.
At the clinic, once Shumaker has an understanding of a patient’s goals and symptoms, he and his team conduct a complete and comprehensive assessment of the visual system, including all the functions that are “critical for the dynamic things we do in life, including sports, but also just riding a bike, cooking, or reading on a computer screen or a page.”
Next, the clinic’s optometrists look for opportunities to help, says Shumaker. “The low-hanging fruit, the basic stuff, is hardware,” he says. “A patient may need glasses, or contacts, or their current lenses may be under-correcting. We look for anything simple we can do to make a patient’s visual system more efficient and their vision clearer and we do that first.” They also make sure the eyes are healthy and screen for common ailments, such as dry eyes, that can impact performance.
The clinic then employs more than a dozen tests of critical visual functions, from measurements of dynamic visual acuity to maintaining and adjusting eye alignment or different distances. Other tests include focusing ability, eye-tracking movements, multiple object tracking, visual reaction time, and working memory related to vision.
Such a deep dive into Dublin’s visual system found that he had a severe vertical eye misalignment due to damage sustained to the motor neuron of the superior oblique muscle of his left eye. Dublin tired when reading or writing because his brain had to work extra hard making sense of two incoming images that weren’t fusing together. His brain could do it, but it was so inefficient and required so much processing power that it soon left him exhausted. So, the first thing Shumaker prescribed for Dublin was a pair of prism glasses that would shift how images reached his eyes. Then they set to work on the trickier part, retraining his brain’s control of his eye alignment, which was now inefficient and ineffective because of the injury.
In addition to repetitive and increasingly challenging in-clinic exercises that they did together, Shumaker prescribed Dublin an app made by Vision Science Labs, where Shumaker serves as a scientific advisor. The home training app also exercised Dublin’s eyes in therapeutic ways. “At first, we break these functions down into their simplest aspects and optimize them. Day after day with home practice, and week after week in the office, these exercises gradually re-wire the brain to that more efficient approach. Those improved patterns become hardwired, and the visual system works much better.”
Shumaker starts with a set of basic eye exercises based on the patient’s particular diagnosis, which are then modified each week to maintain a good challenge and progress. When his patients plateau with these basic calisthenics, they focus more on exercises that challenge vision processing and integrate vision with the rest of the body in order to continue to repair and strengthen the impaired functions and return to the activities that were enjoyed prior to the injury.
“Depth perception is critical for bicycling and driving,” says Dublin, and one web-based exercise he worked on for months at home measured and strengthened that function. “It looked like wallpaper, but for people with intact depth perception, there were diamond shapes that popped out as if floating above the plane of the wallpaper. My wife could see them. But for five months I just couldn’t,” says Dublin. “But after six months of exercises, the diamonds suddenly began to float. I could see them!”
On The Road and Back to Work
In late 2021, Dublin passed his driver’s test and he is now happily back at work, too. He has new glasses now as well; while the original ones Shumaker prescribed made a 15-degree correction for Dublin’s double vision, because of the exercises he’s done, Dublin’s new glasses need only make a 2-degree correction for optimal results.
The passage of time likely played a role in his recovery, says Dublin, but he’s certain that the exercises Shumaker prescribed were essential to the full restoration of his vision. And he’s not stopping now. Five months after his last appointment at the Sports Vision and Concussion Clinic, Dublin continues to do online exercises for 15–20 minutes each morning.
Reading is itself a kind of team sport. “When you read, your two eyes are moving, hopefully together and hopefully accurately, several times a second,” says Shumaker. “One’s eyes must pause very briefly to get the gestalt of letters making up a word while simultaneously planning where to go next. And these responsibilities of the visual system—details, timing, planning, and movement—must happen in perfect synchrony. Then they have to move from line to line filtering out lots of information that isn’t relevant when seen, but that might be relevant later. Reading is a very high-demand visual activity. And many people’s visual systems are not up to the task.” The double vision that often results from traumatic brain injury, like Dublin’s, can be especially compromising.
“Luckily, we can help,” says Shumaker.
From Pros to Children
The Sports Vision and Concussion Clinic doesn’t only see patients with problems to fix, though, says Dr. Wilmer. The answer to Shumaker’s introductory question, “What are your goals?” is sometimes, “To get an edge on my competitors, to improve my response time by the fraction of a second that it takes to hit a homerun, block a shot, or return a serve.”
Wilmer points to three populations that give her particular satisfaction when she considers how the clinic can benefit them. The first is youth and collegiate athletes. “They are always thinking about how to be more fit and flexible and strategic in their sport, but they often overlook the potential for visual enhancement to give them an edge.”
Greg Appelbaum, the human performance researcher who referred Beardsley to the Sports Vision and Concussion Clinic, has since become a collaborator of Shumaker’s. They are about to launch a study, together with several other vision researchers around the country, that will help quantify how well the kind of dynamic vision training they conduct improves the hitting performance of collegiate baseball players.
“The positive effects of vision training are notoriously difficult to prove out in clinical research due to so many confounding factors,” says Shumaker. “Well-designed research studies like this one are critical to provide the evidence base for how I practice optometry and the profound benefits of training I’ve observed with my patients.”
Another group that benefits from what the clinic has to offer are those who’ve suffered from concussion months or even years ago and who still have symptoms that may be vision related—even though they may not recognize the connection. “A lot of these people have no idea that there is a visual component to their headaches or their tiredness,” Wilmer says. “Dr. Shumaker has helped a lot of patients who’ve had concussions but have just given up on trying to feel better. Sometimes they come to have regular eye exams and they describe symptoms that can’t be explained away by new glasses, for example,” she says.
“Then, inquiry reveals a traumatic brain injury sometime in their past,” Wilmer says. “Dr. Shumaker will do some key diagnostic testing showing that they have deficiencies based on their injury that he can help with. He can do a lot with interventions even long after the fact. The symptoms are associated with vision, but the patient doesn’t always connect them. They perceive it as, ‘I just get tired when I read’ or ‘I just can’t seem to study for more than 30 minutes.’ That patient probably isn’t going to say, ‘I should go see someone who specializes in post-concussion vision rehab.’ They don’t even necessarily know that such a thing exists.”
But if such concussion patients do find their way to the clinic, Shumaker and his team are often able to discover a vision connection to their symptoms and to help them alleviate those symptoms… or to learn to better live with them, says Wilmer.
Shumaker is conducting an NIH-funded study in collaboration with the Smith-Kettlewell Eye Research Institute that examines the photoreceptor pathways in the retina and their role in light sensitivity after concussion. “Light sensitivity is a very common and debilitating post-concussion symptom that can persist for years unless addressed properly,” says Shumaker.
The third group that Wilmer points to are patients who remain active athletes well into retirement with a little help keeping their visual systems optimized. Paul Ramsey, the hardball player in his 60s, for example. He lives for the comradery, the excitement, and the exercise of his sport, Ramsey says.
But before he found the clinic, he was about ready to give it all up. Between the exercises in-clinic and his app-based vision-strengthening homework, however, over a couple of months, Ramsey’s batting improved. “After diligently performing the eye exercises,” he says, “the strikeouts stopped and I began getting hits again, often driving the ball for extra bases.” Toward the end of the season, he was nearly back to his old average. He says it was like winning back decades of satisfaction on the field and on the golf course.
“I think the combination of playing the game and having these friendships is what keeps guys like me in really good shape, both mentally and physically, into their 70s and 80s,” says Ramsey of his senior baseball league. “My vision is to keep playing baseball with these guys as long as I can.” And with the help of Dr. Shumaker and the Sports Vision and Concussion Clinic, that vision might just come true.