Key Points

• Not only do stress hormones trigger responses like making your heart race, breath quicken, and muscles prepare for action, but the eyes react to emotional influences as well.

• When a stress response keeps firing day after day, it can affect vision in a way that leads to struggling to see and the typical response of eyestrain, eye tension, headaches, stiff neck, back and shoulder pain, and body aches.

In an ideal world, we would all develop healthy vision that is efficient, relaxed, and comfortable. But today, we are experiencing an increase in vision issues, caused by three widespread, ongoing issues that contribute to these musculoskeletal problems: myopia and dry eyes brought on by screen time,¹ diabetes with increasing cases of diabetic retinopathy,² and historically high levels of life stress.³ 

According to the Centers for Disease Control and Prevention (CDC), as the population of older people increases, the number of people experiencing vision loss will increase too.⁴ Let’s look at how these issues are causing an eyestrain epidemic, and how LMTs can help themselves and their clients. 

Diabetes

Ten percent of all Americans, about 34 million people, have diabetes, which is the leading cause of blindness in working-age Americans. Massage therapists are not immune to this disease either.⁵ About one-third of our diabetic clients, friends, and family members will develop a complication called diabetic retinopathy. High blood-sugar levels cause progressive damage to the blood vessels of the retina and the light-sensitive lining at the back of the eye. As their vision worsens (blurred vision, fluctuating vision, double vision, dark or empty areas, no vision at all), sufferers squint and stare and strain to see. 

This naturally creates ongoing eye pain, eye fatigue, neck strain, and an increased chance of headaches. Obviously, many people can be saddened or depressed by these impairments. Ophthalmologist Bernhard Sabel says the stress of the diagnosis may even worsen the disease. He promotes counseling, meditation, stress management, and other holistic techniques to help his patients.⁶ 

Emotional Stress

A 2022 survey by the American Psychological Association on stress in the US found that a large majority of Americans felt they were experiencing high levels of stress over longer periods of time due to worries about climate change, the economy, the COVID-19 pandemic, and the war in Ukraine.⁷ 

Where exactly stress is expressed in the body may be different for different people—but for many, stress can affect their eyesight. For example, the fight-or-flight response to stress affects many parts of the body, including the entire visual system. Not only do stress hormones trigger responses like making your heart race, your breath quicken, and your muscles prepare for action, but the eyes react to emotional influences as well. For example, if we see something we like, the pupils grow bigger; if we see something distasteful, they shrink to pinpricks.⁸ Eye pressure can increase due to anxiety, depression, mental fatigue caused by difficult mental tasks, or after a tiring vision task such as driving.⁹ Under emotional stress, problems with blood vessels can cause a lack of blood to vital eye structures; ischemia of the optic nerve or retina can lead to vision problems.¹⁰

The role of stress in vision problems has been recognized throughout history. In 500 BCE, the Greek historian Herodotus described an Athenian warrior who was so frightened during a battle that he lost his vision permanently.¹¹ In India in 300 BCE, an Ayurvedic surgeon listed some of the causes of vision loss as “continuous crying, grief, excessive anger, and suppression of tears.”¹² Some soldiers after World War I had what was then called hysterical blindness—a loss of vision with no anatomical injury. A modern example is a group of Cambodian women who immigrated to the US after the Cambodian genocide of 1975–1978. After being examined by eye doctors who found there was no anatomical problem for their poor vision, the women were treated with counseling and social support classes, and their vision improved. Several stories emerged from women who were interned in a Khmer Rouge camp, where they witnessed tremendous violence. One said, “I started crying hard for a long time . . . later when I finally stopped crying, I could not see.” Another said, “Sometimes I will get a headache if I think about my sister in Cambodia. Then I will get pain all over my body and my eyes will hurt.” The longer the women were in the camps and the more trauma they witnessed, the more their vision was impaired.¹³

When a stress response keeps firing day after day, it can lead to eyestrain, eye tension, headaches, stiff neck, back and shoulder pain, body aches, and general struggles with vision. 

Myopia

Myopia was already a growing problem in the US before COVID-19, with its prevalence increasing from 25 percent of Americans in the 1970s to 42 percent in the 2000s. It has increased even more due to the COVID-19 pandemic and screen time. According to ophthalmologist Sylvia Woo at Tufts University School of Medicine, “Today’s epidemic of myopia in young people seems to be related to general lifestyle changes where kids are just generally spending more time inside using the screen, doing more near-point activities . . . we have had many young patients complaining of eyestrain or being diagnosed as nearsighted (myopic) or more nearsighted since the start of the pandemic.” How does this lead to myopia? Many hours looking at lighted screens while focusing at the same distance is hard work for the eyes, which are better designed for distance vision in natural light. According to evolutionary biologist Daniel Lieberman, “More effort is needed for the eye muscles to focus on a near object than a far one . . . When we watch TV or read a book, it is not just closeness that causes the problem but lack of variation in the depth of vision. This forces the eye muscles to hold a particular degree of contraction for an unnaturally long period.” This can overwork the eyes, and according to optometrist Marc Grossman, “If the six small muscles which move the eyeball are misused, underused, overworked, or used unevenly, a vision problem can result.” 

A worldwide research review found that the odds of becoming myopic increase significantly with more up-close time and Americans now spend about four hours a day doing just that, reading and texting on their smartphones and devices.¹⁴ Upper-body tension can also result when someone is myopic. For example, overuse or injury of the extraocular muscles, which help move, stabilize, and align the eyeballs, can activate trigger points that refer pain to the head and neck and contribute to tension and migraine headaches.¹⁵ Nearsighted people tend to be much tighter in the trapezius and sternocleidomastoid muscles than those who are not.¹⁶ In one study, electrodes placed on the trapezius muscles showed that difficult near-work tasks led to significantly increased contractions.¹⁷

Myopia can activate trigger points in the occipitalis muscle by constant contraction of the forehead and scalp muscles, and troublesome trigger points in the suboccipital muscles can develop from forward flexion of the head and neck.¹⁸

If someone is light sensitive and hangs their head to avoid glare from overhead lights, this leads to squinting and creates trigger points in the orbicularis oculi and an anterior head posture.¹⁹ 

Slouching and a head-forward posture, common when using screens, also leads to tightness in the pectorals, upper trapezius, levator scapulae, scalene, and sternocleidomastoid muscles, and weakness in the deep neck flexors, rhomboids, and serratus anterior muscles. Since slouching tilts the head down, the person must contract the suboccipitals to extend the head and neck when they want to look straight ahead. The load on the neck muscles to keep the head from falling forward is huge. “With your head hung over your device at just 45 degrees, your neck muscles are doing the work of lifting a 50-pound bag of potatoes,” says David Riew, a cervical spine surgeon. 

The spine conforms to the way we use our eyes. A 2001 study in Spine found that children who were severely visually impaired were much more likely to have twisted or turned heads and scoliosis than children who were not.²⁰ One of optometrist Melvin Kaplan’s patients, a 16-year-old learning-disabled boy, had a 20-degree spinal curvature. After vision therapy, his curve decreased to 12 degrees.²¹

Even a tiny malfunction can cause a person who is doing extensive up-close work to strain more. In a condition called strabismus or “lazy eye,” when it is not easy to align the eyes, up-close work for extended periods of time is even more of a strain. Let’s illustrate this dynamic using strabismus, in which the child’s eyes may point in different directions simultaneously. One eyeball muscle may be weak or paralyzed, one eye is higher than the other eye, or one eye may roll out away from the other. To use the eyes comfortably—and use them together—a child may unconsciously twist or turn the head or tilt the shoulder. For example, when one eye is higher than the other, the child keeps the eyes level by tilting their head, eventually creating chronic tension in the neck and upper trapezius muscles, sometimes causing scoliosis of the neck vertebrae. Surgery may be a cosmetic fix but not actually heal the problem. A surprising number of adults can have this problem. As an adult, one woman who was nearsighted and had one eye that tended to flip vertically adapted like this: “I found I could eliminate my problem by squinting hard and tilting my neck at a 10-degree angle from vertical. This naturally created progressive eyestrain and considerable fatigue.”²²

How to Help Clients with Vision-Related Issues

Bodywork 

The first step in helping a client whose visual habits cause chronic tension or discomfort in the eyes, face, neck, shoulders, or spine is to make them aware that this could be an issue. Your clients will be amazed how much better their eyes, neck, and shoulders feel after bodywork. Start by asking important questions on your client intake forms.

Step 1:Include vision-related questions in your intake form.

• “Do you have chronic neck and shoulder tension?” 

• “Tell me about your vision.”

• “Do you wear glasses?” “Are they comfortable?”

• “Do you have any of the following: trouble seeing, eyestrain at work, discomfort after working on a computer, vision problems, light sensitivity, dry eyes, or headaches?” 

Step 2:Everyone wearing glasses should be checked for tension in the eyes, neck, and spine. Try testing your client’s neck range of motion with and without their glasses on. 

Step 3:Note any head tilts or twists.

Step 4: Address tension during a session. Begin the session by helping the client relax their eyes: 

• Consider drawing curtains or dimming the room lights. This is often soothing for someone with light sensitivity or an eye disease such as macular degeneration.

• Cover the eyes with a warm or cold eye pillow, a warmed towel over the eyes, or a hot and cold contrast treatment while you massage the neck and shoulders.

• Begin by having the client consciously relax the eyes. For example, ask the client to inhale and squeeze the eye muscles tightly, hold for a few moments, then exhale and relax the eyes completely. Repeat twice.

• Have the client perform a few simple eye muscle stretches by having them roll their closed eyes in different directions.

Add more specific massage techniques with work around the eyes, such as: 

• Swedish massage of the face

• Face tapping/tapotement on the forehead and around the eyes

• Acupressure points around the eye orbits

• Classic acupressure points for eye tension on the back of the neck (the bladder 10 points)

• Swedish massage on the posterior neck and upper back

• Trigger-point work on the rectus capitis posterior muscles. This counteracts the fixing of the suboccipitals.

• Craniosacral therapy

Step 5:Be ready to refer your client to a friendly, holistic eye-care professional. For some clients to see clearly with their heads held in an upright, balanced position and without chronic tightness in their posterior cervical muscles, they may need a prescription for a longer focal length or larger bifocal inserts or have an adjustment of their eyeglass frames. An optometrist with advanced training in vision therapy can be found on the College of Optometrists in Vision Development website at locate.covd.org. 

Self-Care 

Step 1: Show clients how to treat their eye and neck tension at home with warm and cool packs for the eyes, eye muscle stretches, and self-massage. The chance of becoming nearsighted decreases with habits of taking regular breaks after close work, doing eye exercises, and spending more time outdoors.²³

Step 2:Encourage the client to check the ergonomics at their workstation. For example, to avoid chronic strain in the posterior cervical muscles, the computer monitor may need to be raised or moved farther away for reading, and work materials may need to be at a different angle or height. Perhaps the client works for a company that has staff who can do ergonomic consultations. An ergonomic assessment is a comprehensive evaluation of a person’s workstation that looks at factors such as posture, body positioning, and repetitive movements.

Step 3:Provide the resources to the client found on page 54. 

Be the connection for your client

For many clients with chronic upper body tension due to vision issues, it’s often the case that no one has ever mentioned that the two are related. Although they may love the relief of a massage, they can still become discouraged about continuing bodywork when the same problems return soon after each session. When you can help clients make the connection between the two, it can be a revelation. Add a bodywork session that blows them away with relief of their eyestrain, some simple self-care methods, and a referral to eye-care professionals that can help them deal with the cause of the problem. 

Notes

1. Frederic Dutheil et al., “Myopia and Near Work: A Systematic Review and Meta-Analysis,” International Journal of Environmental Research and Public Health 20, no. 1 (2023): 875; M. E. Helander, S. A. Cushman, and S. M. Monnat, “A Public Health Side Effect of the Coronavirus Pandemic: Screen Time-Related Eye Strain and Eye Fatigue,” Population Health Research Brief Series 50 (2020), https://surface.syr.edu/lerner/50.

2. CDC, “Fast Facts About Vision Loss,” last reviewed December 19, 2022, www.cdc.gov/visionhealth/basics/ced/fastfacts.htm; Abraham Flaxman et al., “Prevalence of Visual Acuity Loss or Blindness in the US,” JAMA Ophthalmology 139, no. 7 (2021): 717–23. 

3. American Psychological Association, “Stress in America 2022,” October 2022, www.apa.org/news/press/releases/stress/2022/concerned-future-inflation.

4. National Eye Institute, “Eye Disease Statistics Fact Sheet,” www.nei.nih.gov/sites/default/files/2019-04/NEI_Eye_Disease_Statistics_Factsheet_2014_V10.pdf; Flaxman et al., “Prevalence of Visual Acuity Loss or Blindness in the US.”

5. CDC, “Fast Facts about Vision Loss;” A. Cha, M. Villarroel, A. Vahratian, “Eye Disorders and Vision Loss Among U.S. Adults Aged 45 and Over with Diagnosed Diabetes, 2016–2017,” National Center for Health Statistics Data Brief 344 (2019): 1–8; IDF Diabetes Atlas, www.diabetesatlas.org/data/en/country/211/us.html.

6. Bernhard Sabel et al., “Mental Stress as a Consequence and Cause of Vision Loss: The Dawn of Psychosomatic Ophthalmology for Preventive and Personalized Medicine,” EPMA Journal 9, no. 2 (2018): 133–60.

7. American Psychological Association, “Stress in America 2022.”

8. Desmond Morris, Bodywatching (Crown Publishers, 1985).

9. Ricardo Abe et al., “Can Psychologic Stress Elevate Intraocular Pressure in Healthy Individuals?,” Ophthalmology Glaucoma 3, no. 6 (2020): 426–33; Bernhard Sabel and Luisa Lehnigk, “Is Mental Stress the Primary Cause of Glaucoma?” Clinical Monthly Journals for Ophthalmology 238, no. 2 (2021): 132–45; Jesus Vera, “Analysis of Oculo-Visual Parameters as Biomarkers of Physical and/or Mental Effort,” PhD thesis, University of Granada, Spain, 2016.

10. Ann Hoopes, Eye Power (Knopf, 1979).

11. Jennifer Roberts and Tracy Barrett, The Ancient Greek World, (Oxford University Press, 2004).

12. Sabel, “Mental Stress as a Consequence and Cause of Vision Loss: The Dawn of Psychosomatic Ophthalmology.”

13. Gretchen Van Boemel and P. Rozee, “Treatment for Psychosomatic Blindness Among Cambodian Refugee Women,” Women & Therapy 13, no. 3 (1992): 239–66. 

14. Dutheil et al., “Myopia and Near Work: A Systematic Review and Meta-Analysis.”

15. Cesar Fernández-de-Las-Peñas et al., “Referred Pain from Trochlear Region in Tension-Type Headache: A Myofascial Trigger Point from the Superior Oblique Muscle,” Headache 45, no. 6 (2005): 731–7; Cesar Fernández-de-Las-Peñas et al., “Myofascial Disorders in the Trochlear Region in Unilateral Migraine: A Possible Initiating or Perpetuating Factor,” Clinical Journal of Pain 22, no. 6 (2006): 548–53; Cesar Fernández-de-Las-Peñas et al., “Referred Pain Elicited by Manual Exploration of the Lateral Rectus Muscle in Chronic Tension-Type Headache,” Pain Medicine 10, no. 1 (2009): 43–8.

16. B. Valentino and A.  Fabozzo, “Interaction Between the Muscles of the Neck and the Extraocular Muscles of the Myopic Eye. An Electromyographic Study,” Surgical and Radiologic Anatomy 15, no. 4 (1993): 321–3.

17. H. O. Richter, C. Zetterberg, and M. Forsman, “Trapezius Muscle Activity Increases During Near Work Activity Regardless of Accommodation/Vergence Demand Level,” European Journal of Applied Physiology 115, no. 7 (2015): 1,501–12.

18. D. Simons, J. Travell, and L. Simons, Myofascial Pain and Dysfunction: The Trigger Point Manual Vol. 1, 2nd ed. (Baltimore: Williams and Wilkins, 1999).

19. D. Simons, J. Travell, and L. Simons, Myofascial Pain and Dysfunction: The Trigger Point Manual. 

20. J. Catanazariti, “Visual Deficiency and Scoliosis,” Spine 26, no. 1 (2001): 48–52.

21. Melvin Kaplan, Seeing Through New Eyes (Jessica Kingsley Publishers, 2005).

22. Hoopes, Eye Power.

23. Sang-Dol Kim, “Effects of Yogic Eye Exercises on Eye Fatigue in Undergraduate Nursing Students,” Journal of Physical Therapy Science 28, no. 6 (2016): 1,813–15.

Resources

Videos

“3 Quick Ways to Relieve Gamer’s Neck Pain or E-Sport (Computer Users),” www.youtube.com/watch?v=enH2o2ZnBKI.

“This Simple Exercise Will Improve Your Eye Vision,” Andrew Huberman, neuroscientist from Stanford University, https://youtu.be/AA9gyYbhG7I.

 “What It Means When You Tilt Your Head and How Vision Therapy Can Help,” www.youtube.com/watch?v=RSMPnFHhWt0.

“Yoga for the Eyes: Yogic Eye Movements,”
www.youtube.com/watch?v=OtrXQZT85uM.

Books

Healing Your Eyes with Chinese Medicine: Acupuncture, Acupressure, and Chinese Herbs, by Andy Rosenfarb. Berkeley: North Atlantic Books, 2007. This book contains herbal eye steams, acupuncture, and other Chinese medicine for dry eyes, eye discomfort, and eye diseases.

Natural Eye Care: An Encyclopedia, by Marc Grossman and Glen Swartwout. This book offers information about natural vision improvement and eye health. Keats Publishing, 1999.

Myofascial Pain and Dysfunction: The Trigger Point Manual Vol. 1, 2nd ed. Simons, D., J. Travell, and L. Simons. Baltimore: Williams and Wilkins, 1999.

Research Articles

Huang, Luoming et al. “The Prevalence of Myopia and the Factors Associated with It Among University Students in Nanjing: A Cross-Sectional Study.” Medicine 98, no. 10 (2019).

Theophanous, C. et al. “Myopia Prevalence and Risk Factors in Children.” Clinical Ophthalmology 12 (2018): 1,581–7.

Glossary

Astigmatism is an imperfection in the curvature of the eye’s cornea. It can cause blurry or distorted vision, eye discomfort, eyestrain, headaches, and squinting to try to see clearly. Sufferers tend to have chronic tension in their posterior cervical muscles and migraine headaches.

Eyestrain is a common condition that occurs when your eyes get tired from intense use, such as driving long distances, reading for a long time, crafting, or looking at computer screens and other digital devices. Sufferers may feel fatigue, sore or dry eyes, blurred or double vision, a dull ache behind the eyes, or headaches.

Hyperopia, or farsightedness, means a person has trouble seeing things that are up close but has no problem seeing objects in the distance. It can cause eye strain and headaches.

Myopia, or nearsightedness, makes it difficult to see objects far away, while vision remains good for objects up close. 

Natural vision improvementis akin to physical therapy for the eyes. It consists of exercises to both relax and improve the eyesight, and teaches strain-free use of the eyes.

Strabismusis when one eye may not be in coordination with the other eye. Humans have six eyeball-mover muscles per eye. These muscles constantly receive nerve signals from the brain that control eye movement and allow the eyes to coordinate movements so they are both pointed at the same target.¹ If the system is not working perfectly, one eye may turn in, out, up, or down. Abnormal head positions can include chin up, chin down, tilting of the head to the right or left, face turns to the right or left, or any combination of these abnormal head positions. 

Vision therapyis an optometric program consisting of supervised in-office and at-home exercises performed over weeks to months along with other treatments, such as glasses, certain machines, or computer software programs.

Note

1. Valentin Dradoi, Neuroscience Online, “Ocular Motor Control,” last reviewed October 20, 2020, https://nba.uth.tmc.edu/neuroscience/m/s3/chapter08.html.