Evidence Based OT Practice, Part IV: Fact or Fad? A Case Study with Bal-A-Vis-X


This post is part of a series on evidence-based practice in OT. Read the previous posts in the series here, here, and here.

Many rehab therapists have fallen prey to using fad treatments that have little or no evidence to support them. There continue to be many lively Facebook debates and polarized opinions about various occupational therapy interventions. Those who believe the intervention is effective make a point of highlighting the many clients they’ve treated who have experienced significant gains, and non-believers turn their noses up and ignore on any evidence presented by those on the other side. As I’ve stated in previous posts about evidence-based practice, the issue in these cases is not whether to use new interventions without a ton of research evidence behind them, but the lack of clinical judgment and application of evidence-based practice principles when choosing and using OT interventions.


For example, in one setting where I worked I witnessed a department of over 50 experienced and intelligent clinicians buy into the promises of an intervention with only weak evidence to support it due to its extreme popularity in the pediatric professional sphere. No matter that this intervention required costly trainings and materials, was unlikely to be generalizable outside of a highly specific context, and was barely occupation-based – therapists wanted to learn it anyway! I was shocked that the department was spending limited continuing education funds on a popular pseudoscience program rather than a well-researched, evidence-based training that could help clinicians obtain better functional outcomes for young clients. Unfortunately, this is the case in many settings and with many practitioners.


The goal of this post is to closely examine one such program and break down how principles of evidence-based practice can be used to help make a determination about the validity, clinical applications, and utility of this program for occupational therapy practitioners. Read on to learn more about whether the widely-used Bal-A-Vis-X program is an evidence-based intervention or a highly-flawed fad!


About Bal-A-Vis-X

One writer states “Bal-A-Vis-X Balance, Auditory, Vision eXercises provides 1,000s of rhythmic midline crossings that enable the mind-body system to experience the state of integration.” (http://in2gr8ed.org/wp-content/uploads/2017/10/apr17.pdf)


On the Bal-A-Vis-X website, the program is described as follows:

Bal-A-Vis-X is a series of Balance/Auditory/Vision eXercises, of varied complexity, all of which are deeply rooted in rhythm. Exercises are done with sand-filled bags and racquetballs, sometimes while standing on a balance board. In distilled essence, Bal-A-Vis-X enables the whole mind-body system to experience the natural symmetrical flow of a pendulum. Bal-A-Vis-X requires focused attention, demands cooperation, promotes self-challenge, and fosters peer teaching. It is school friendly and just plain fun.” (http://www.bal-a-vis-x.com/about.htm)


The website also includes links for purchasing materials, scheduling trainings, customer testimonials, and research articles. It is fairly simple, and appears to have been recently updated. The site mostly features information from program users and instructors touting its benefits for young clients and links to a few companies that “have created materials especially for Bal-A-Vis-X and are the ONLY authorized dealers for Bal-A-Vis-X in the world.” This last part seems a little strange, especially considering that most of the program materials (sandbags, racquetballs, balance boards), with the exception of the mysterious “VISTar balls,” are fairly inexpensive and easily obtained or replicated by program users.

After a brief review of the program website, the real work of uncovering evidence, identifying inconsistencies, and applying research and clinical reasoning skills begins.



  • Initial Research: Typing Bal-A-Vis-X into Google Scholar yielded few relevant results. A primary result was a citation from a publication by Bal-A-Vis-X creator Bill Hubert. Additionally, the citation was from “Bal-A-Vis-X Incorporated,” which indicates that the “research” was produced by the company itself, rather than an independent source. Despite having been around since 2014, the source was also only cited by 10 other sources. A quick review of these sources showed that they varied in quality, “reliability” and age. Further, the underlying principles on which the program is based (positive effects of midline-crossing activity, brain laterality, and physical movement on learning) appear to be sound. However, the impact of these principles of Bal-A-Vis-X program – in comparison to innumerable other activities that require similar skills (sports, dance, table games, yoga, etc.) – on participant outcomes is unclear.


  • Research Quality: Many of the “studies” linking the use of Bal-A-Vis-X to improved client outcomes violated the foundational principles of research, basically invalidating them from the start. For example, almost none of the “studies” were single- or double-blind, and most researchers openly stated a bias towards the effectiveness of the intervention. Additionally, most papers presented an overly simplistic “cause and effect” or correlative conclusion definitively linking the use of Bal-A-Vis-X to improved academic and behavioral outcomes – neglecting to take into account confounds or alternative explanations (see below).

    I could easily identify even more issues that seriously compromise or outright disprove the validity of each author’s results, such as:

    • Lack of a control group
    • No clear intervention protocol (limiting ability to replicate study)
    • Outdated, low-quality, or minimal references
    • No discussion or acknowledgement of potential confounds or other causes for study outcomes (i.e. increased attention paid to the study participants, time effects, the impact of the physical exercise component versus the rhythmic “mind body integration” component of the exercises, and the effects of typical brain development over time)
    • Non-standardized assessments used as benchmarks


At best, a reader of the papers included on the Bal-A-Vis-X website could conclude that students enjoyed the intervention and their typing performance or classroom behavior improved over time. However, it is not reasonable to conclude that the program had any measurable effect other than being subjectively enjoyed by participants and administrators.

  • Levels of Evidence: After the initial Google Scholar search, I used the research pyramid to determine where the Bal-A-Vis-X program fit. The site’s “Research” page listed only three studies, which were all case studies implemented with a variety of methods and by individuals who clearly did not have extensive or high-quality research experience. Thus, the Bal-A-Vis-X program falls in one of the lower tiers as a “Case Study.” While qualitative research is also important for informing OT practice, clinicians should be wary of basing their clinical decision-making solely on anecdotes and individual client reports.
  • CRAAP Test: The CRAAP Test is a list of questions to help you evaluate the information you find about a specific intervention, program, or topic.
    • Currency: The lack of recent research (within the past 4-5 years) for the program is concerning, with most of the sparse studies on the “Research Results” page having been conducted from eight to thirteen years ago. The program also does not appear in recent systematic reviews, critically appraised topics, or other sources from professional associations or other reliable sources.
    • Relevancy: The program has been used with people of all ages and in various settings, so it may be relevant for OT practice. However, I would not feel comfortable citing the “research” listed on the site in a formal presentation or conversation with caregivers or colleagues. The program also appears to be fairly decontextualized, which does not align with the principles of occupational therapy practice.
    • Authority: The author is the owner of the Bal-A-Vis-X company, which may be a conflict of interest (but this not uncommon for program creators). He was formerly an experienced teacher and martial arts instructor.
    • Accuracy: Most of the information on the site comes from the creator’s experience, informal research projects, or customer testimonials. The information is primarily supported by personal anecdotes and case studies, and has not been validated by independent researchers or other reliable entities. When attempting to verify the information via Google search, several results describing the program as “pseudo-science” appear.
    • Purpose: The purpose of the program appears to be helping participants succeed (in various ways) and encouraging readers to participate in Bal-A-Vis-X trainings. Thus, there are altruistic and financial purposes for the program, which is true of many interventions.
  • Sources Cited: The “research studies” listed on the site are actually case studies by individuals who do not have clear research experience. The protocols described in the papers vary widely yet arrive at the same conclusion. Personal biases about the expected (positive) effect of the intervention decrease credibility. Additionally, the program can only be used after individuals pay to participate in a training course and purchase materials, limiting its generalizability and possibly increasing participant bias towards its effectiveness.
  • Professional/Expert Opinions: In the case of Bal-A-Vis-X, there are multiple expert opinions online that agree that the evidence base is extremely weak and the efficacy of the program (in comparison to control groups or other treatments) is unclear. Each person makes a point of saying that although the program doesn’t cause harm to users – although it clearly is at risk of causing significant harm to the perception and practice of OT – it is misleading for instructors to claim that it is evidence-based.

    “The Bal-A-Vis-X website posts its own research page, but you won’t find any gold-standard studies here. As with any intervention program, I’d caution you against using research posted on the company’s website. Obviously, no company would want to post research with refutes their claims. The “research” (and I use the term loosely here) supports the effectiveness of Bal-A-Vis-X. The “research” is little more than a handful of kindergarten students and teachers who wrote anecdotal commentary about how keeping kids active improved their academics. No doubt, activity is good for students. I do have doubt that it was the Bal-A-Vis-X method specifically which produced the results. My hypothesis is that the same amount of time given to playing basketball or other physical activity within the classroom would also increase students’ socialization, self-esteem, and general academic performance. Go ahead, prove me wrong.While writing this post, I came across this similar post from Musikinesis.com, which shares both my doubts about Bal-A-Vis-X and my general belief that it’s okay to use a program as long as it doesn’t hurt kids. It’s just important that we don’t tout the research effectiveness of such programs when the research to support them is substandard.…I don’t necessarily feel that it’s wrong to use a program without research to back up its effectiveness, but I certainly don’t think we should promote those programs as being effective unless the research concurs.” (Jason Wright, EdS, GCG)“There are three research studies linked on the site. They are all designed and conducted by, no doubt, sincere and well-meaning teachers. But you don’t have to be a scientist to recognize that the studies aren’t scientifically valid. As in many such studies, Bal-a-Vis-X process and effects aren’t distinguished from any other movement – jogging, dancing, sports, etc. We don’t know what, if anything, the control group did with their time, so it’s unclear whether any exercise, or other exercises with particular features, would have shown the same result.

All three studies begin with presuppositions about Bal-a-Vis-X. There’s nothing wrong with having biases or expecting particular results, but the studies were not double- blind or even single-blind, opening up huge possibilities for the testers’ own biases, behaviors, and expectations to influence results.

Much of the hypotheses rest on the same debunked theories aligned with BrainGym…None of the studies describe random groupings. One grouped the students by classrooms, introducing different peer dynamics, classroom environments, teachers, etc. Sample groups were small, and got smaller, and whether differences were statistically significant isn’t addressed. It’s also unknown whether pre- and post- tests were administered under the same conditions. Like BrainGym, Bal-a-Vis-X is selling around the world.” (Monica Dale, Master of Music, Piano, Dalcroze)


“As an OT who has practiced in the school systems for 10 years in 5 different states, I can confirm that this blatant lack of regard for evidence and rigor in our field is stunningly widespread. …My current contract has me working in a region program that has accepted Bal-A-Vis-X as the corner stone of their intervention plans. Not only are these therapists wrongly applying a pseudoscience based perceptual motor program to a broad range of students (from the student with a mild case of ADHD to a child with severe CP who has limited hand functioning) with a subjective treatment goal (improve attention) but the most frightening thing is they appear to not be able to recognize pseudoscience.

I have seen this inability played out over and over again in each district and state that I work in….

My second point, and I think the most important one is, the responsibility does not end with the leaders in the OT world, as street level therapists we must demand more from our colleagues. It should not be acceptable to receive a file from a therapist with limited documentation, sparsely informative evaluations and exclusive use of unproven interventions. No longer can we accept whining about caseload size and driving times as legitimate reasons to be ineffective therapists. We must expect that our colleagues are adhering to the code of ethics published by the AOTA that expressly states that evidence based interventions be given preference over those with limited or no evidence behind them…” (Gretchen Scheibel, MS, OTR/L, BCBA)



Ultimately, my findings indicated that while the Bal-A-Vis-X program is well-known and well-liked among therapists, teachers, and others, there is very little compelling or high-quality evidence that the program leads to lasting results or improvements in occupational engagement or performance for users. This isn’t to say that program administrators and participants do not enjoy participating and/or report positive outcomes (improved attention, behavior, etc.) after implementing the program, as there are many Youtube videos, personal anecdotes, and Pinterest Pins indicating that this is true.


However, multiple “red flags” I encountered while conducting my research caused me to categorize this program as anything but a skilled occupational therapy intervention, including:

  • Disparity of approaches and outcome measures used to determine program effectiveness
  • Weak credentials of program founder and individuals writing “research papers”
  • High cost of program training and materials
  • Low quality of evidence on program website
  • Lack of citation within peer-reviewed research articles or other reliable sources
  • Decontextualized, non-occupation-based nature of intervention
  • No long-term follow-up on participants
  • Reputable, qualified professionals describing the program as “pseudoscience” or “not evidence-based”


Perhaps Bal-A-Vis-X is a fun preparatory or therapeutic activity to have in your OT “toolkit,” but OT practitioners should consider whether teaching teachers or caregivers to administer this specific, non-evidence-based intervention is more effective than teaching strategies clients can use across settings, time, and populations to improve client participation and occupational performance.

When I consider how to make the most of the treatment time I have with caregivers, teachers, and clients – especially with their limited time and resources – I do not believe that using this intervention would be as effective in providing skilled instruction in environmental modification, adaptive equipment, sensory modulation, universal design [for learning], cognitive strategies, and other evidence-based, client-centered, and occupation-based occupational therapy interventions.


This is my interpretation of the information I found, and readers are free to arrive at their own conclusions. However, I believe that the evidence above makes a compelling case for why Bal-A-Vis-X should be viewed as a “brain game,” movement break, preparatory activity, or play/leisure activity rather than an evidence-based intervention that will lead to specific functional outcomes for occupational therapy service users or others with and without special needs.

12 thoughts on “Evidence Based OT Practice, Part IV: Fact or Fad? A Case Study with Bal-A-Vis-X

  1. C Duke October 28, 2018 / 7:23 pm

    Thank you for the interesting post. I’m currently looking at the Pros and Cons of BalAVisX so I thought this article was very insightful. That being said, I wanted to say as a fellow OT, I question whether or not we can refute the effectiveness of balance and juggling activities as “lacking evidence” if the student (I’m a school-based OT) considers the activity to be meaningful and novel. I mean, what does it promote? Visual tracking, bilateral coordination, dynamic balance, hand-eye coordination, visual motor integration, or more generally – timing, focus/concentration, frustration tolerance, etc etc. the list goes on. I mean, isn’t this what we do? Expose our clients to novel modalities that work on these skills so they may in turn translate to other activities? In a sense, we trick our clients into working and having fun. You’re right – the EBP in BalAVisX is lacking, but I don’t think this fully discredits its effectiveness as a potentially effective intervention. Have you tried it?

    That being said, honest question – where do you find EBP for effective interventions that improve handwriting, copying, and attending to task? I’d sincerely like to know. My practice is lacking in this department, and I’ve about had it with pre-packaged training modalities.

    Lastly, pardon my saying, you cited that “sensory modulation” was evidence-based. Even with sensory modulation and sensory integration we lack firm evidence and research… but we (as OTs) know just how helpful it can be to address a sensory problem with a client. I suppose the point I’m trying to make is that not everything we do can be backed by evidence and research… and yet we’re effective. Sometimes the classics are classics because they’re effective regardless of its evidence-based backing.

    • lej1123 October 29, 2018 / 9:04 pm

      Thanks for commenting! I appreciate the questions you posed and ideas you shared. I agree that as therapists — especially in pediatrics, but also in other settings — we use various activities (or occupations!) as therapeutic interventions in an effort to build skills “indirectly.” However, I think we need to be careful about straying too far from the occupations we are hoping to impact when we are building skills “indirectly,” as the research shows that having clients perform simulated or non-purposeful tasks does not always translate into improved occupational performance (see #1 and #1 at the link, https://goo.gl/mPQkFB).
      For example, doing an indoor ice skating activity with wax paper “skates” is probably great for improving coordination, BLE strengthening, activity tolerance, etc. However, if the ultimate goal was to have a child actually ice skate in a rink, it’s questionable as to whether or not the skills from the wax paper skating activity would translate into effective skating on ice. Similarly, having a marathoner practice only on an indoor treadmill and then expecting them to have the same outcome when competing in an outdoor road race is unwise. Ultimately, it’s not clear that the activities of the BAVX interventions actually translate into meaningful changes in students’ abilities to participate in classroom settings – although they MAY improve foundational/underlying skills (visual coordination, endurance, coordination, etc.) and provide insight into strategies that may be useful for students (activity breaks, social skills, etc.). Therapists should be careful to not just ASSUME that the skills targeted by interventions like BAVX will translate to the actual activities, but instead should be explicit with clients about use of things like pegs or clothespins (or BAVX) as preparatory activities rather than primary interventions/treatments. I have not tried BAVX, but as I stated in the post there is just not enough evidence of BAVX’s effectiveness on occupational performance and outcomes to justify me using it INSTEAD OF other interventions – although it has potential as a good complementary, warmup, or therapeutic activity.

      That said, I think that there is always room for creativity with interventions; just last week I did a “burger flipping” activity with a stroke patient who worked as a grill cook; we used a real spatula but the burgers were beanbags. Working at the hospital, I did the best I could with limited resources, keeping in mind that during the intervention I also needed to discuss/address activity factors, patient factors, and other issues that were not present with a simulated activity (i.e. a hot grill, managing fatigue, sensory changes and safety, production demands at work, etc.).

      Regarding effective handwriting interventions, the good news is that there is some research in this area you might find helpful:
      https://ajot.aota.org/article.aspx?articleid=1851521 (This article also describes multiple other handwriting intervention studies and their underlying principles that allegedly helped students improve handwriting)
      Essentially these articles state that adequate “therapeutic practice” of handwriting, >20 practice sessions, and direct instruction in letter formation and good writing habits, rather than “sensorimotor interventions” (defined as activities related to visual perception, visual-motor integration, proprioception/kinesthesia, and in-hand manipulation) led to improved handwriting outcomes.

      Finally, I realize that not every OT intervention has a formal research or evidence base, and discussed this in the first post in this series. In writing these posts, my main point was not to assert that every intervention should have a published research article backing it, but to have readers increase their understanding of EBP and challenge themselves to reflect critically and improve the quality of their evidence/practice rather than simply relying on “the classics” without understanding why or how they are effective (or not).

  2. radaintholistics November 28, 2018 / 12:46 am

    Great article. Really helpful and reliable. Thanks for sharing this and keep up the good work, very much appreciated

  3. Rebecca July 28, 2019 / 11:20 am

    Thank you for analyzing the effectiveness of BAVX as an intervention tool. As a new OT practitioner in a school setting, I want to offer meaningful, evidence-based interventions to my students. I will keep BAVX as a “brain break” or warm-up activity, and use it to increase the participation of my students in higher level, occupation-based tasks. Thanks!

  4. Harry Weaver September 10, 2019 / 12:07 pm

    If we analyze what therapists do in real school settings. I would doubt that any technique or treatment lends itself to accurate research. We are fooling our selves thinking that this is even possible. All we can do is apply strategies and techniques that make sense from our non scientific training.
    Show me any scientific study relating to OT and you will find flaws and qualifications that the outcome requires further study or that results seem to show effectiveness. Don’t fool yourself thinking you are a scientist.

    • lej1123 October 30, 2019 / 7:52 pm

      Thanks for commenting! I agree that some OT interventions don’t have strong evidence of effectiveness, perhaps only correlation or another link to outcomes. However, the beauty of an evidence-based approach to practice is that it incorporates not only formal research/studies, but clinical experience and patient/family perspectives to create the best possible intervention. As for the scientific basis of our profession, the Science Council defines a scientist as “someone who systematically gathers and uses research and evidence, making a hypothesis and testing it, to gain and share understanding and knowledge.” And I do in fact do this in my job as an occupational therapist every day! Finally, every valid study that has ever been published has flaws and limitations published within it, so that others can use them to improve upon future studies/research — this doesn’t mean that the information is invalid, just that more information is required.

    • schoolpractictioner December 4, 2019 / 12:46 pm

      Couldn’t agree more. I work in a related profession and I think that we are conditioned to prefer “evidence based interventions”….which makes sense. Who wouldn’t want to provide treatment that has been proven to be effective? In my field (school psychology), the problem with this is that there are actually VERY FEW “evidence-based interventions” that are linked to underlying cognitive deficits. The fact is, we don’t have research to show that if a student has deficits in x, y, z cognitive areas, these are the interventions we should use. With the exception of a few reading related skills, the research simply doesn’t exist. YET, the law and a lot of professionals in the field preach that it is important to apply evidence based interventions that are linked to the skill deficits. I think we’re in this trap where evidence-based sounds super great on paper, so everyone uses the term from practitioners, to test publishers, to intervention program creators….even when the research to support it is almost null. In the end, I think as practitioners, we have to rely on our professional judgment and experiences. If we’ve used strategies or practices that we feel have shown improvements in our clients, then keep doing it!! A lot of our work relies on creativity, and trial-and-error. What works for one client, may not work for another. I know “trial-and-error” sounds awful compared to “evidence-based” but in my opinion the latter is still lacking.

      • lej1123 January 4, 2020 / 9:15 pm

        Thanks for commenting! You make a good point about balancing the “evidence base” with clinical judgment and client experiences, but these are also valuable forms of evidence per the EBP triangle! As the evidence base continues to grow, I hope more clinicians will be more comfortable learning about and trialing (and possibly erring with!) new interventions.

  5. occupationaltherapybelowzero October 31, 2019 / 10:06 am

    Well written and informative. I will use some of these activities in my very rural school district as warm up, brain break and whole class exercises. I think the kids will like them and they will promote crossing midline, tracking, eye-hand coordination. No, I am not going to a training and I am going to use regular racquet balls and sandbags. A few activities are easy to teach, fun and teachers like a cookbook for activities. Not an exclusive treatment approach, but like you said a nice warm up or social activity. Thanks.

    • lej1123 January 4, 2020 / 9:11 pm

      Thanks for commenting! I hope you enjoy incorporating elements of the Bal-A-Vis-X program into your OT practice.

  6. nina January 16, 2020 / 3:13 pm

    Hi, I loved this discussion which helped me discern the role bal a vis X could have in therapy. I feel it has the strength of using the co-ordination and movement, and as an SLP use of words in an active and engaging task. It also allows the young mind to watch the process of learning through repetition in a movement orientated activity and regulate themselves to sustain and build upon skills. I thought the pricing and training was way to high and their evaluations of the effectiveness of the program was way beyond. However it does have a place in my tool box and I loved reading your OT perspectives

    • lej1123 February 24, 2020 / 10:04 pm

      Thankbuis for commenting! I also think BAVX is an engaging way to address multiple skills as an intervention, but is quite overpriced and oversold by its founders!

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