Visua impairment and physiotherapy The best of both: working together to support chidren with visua impairment and additiona compex needs A series of eafets exporing ways that the QTVI (Quaified Teacher of Visuay Impaired chidren) and other professionas can achieve an effective working reationship together and ensure the best outcome for chidren with specia requirements. This eafet has been written by Catherine Southwe (QTVI, Woverhampton) and Kathy Haigh (Paediatric Physiotherapist, Leeds PCT).
The team A chid with a combination of disabiities is ikey to receive continued support from severa agencies, each to address a medica, educationa, therapeutic or socia need. Each supporting professiona wi have their own expertise, priorities, methods of working and aims for the chid. In this series of eafets we ook at the above scenario and expore ways that the QTVI can support effective team work with other professionas. We aim to discover how good communication and joint working can hep to: eiminate seemingy conficting or confusing practice for both professionas and parents avoid, or sove, practica probems co-ordinate working practice, aims and targets to ensure the best possibe outcome for the chid. Other tites in the series incude: Visua impairment and occupationa therapy Visua impairment and orthoptics (cinica and functiona vision assessment) Visua impairment and speech and anguage therapy Visua impairment and specific medica needs and medication. How the physiotherapist and the QTVI can achieve the best of both Vision and movement are cosey inked in many respects. The QTVI and physiotherapist wi find many areas of common ground when working with the same chid. Of course each professiona is quaified and experienced in his or her own speciaist roe, and it is important that this is aways recognised and respected. There wi be times when both are satisfied that they are working towards the same goas. There wi aso be occasions when differences in practice may be contradictory. These can, however, usuay be resoved through good communication, improved understanding and sometimes by agreeing on a compromise. 2 Best of both Visua impairment and physiotherapy
Background It is recognised through both practice and research that during the ast two decades there has been a steady and significant change in the popuation of chidren who have a visua impairment. Generay the proportion of chidren presenting with severe or compete sight oss as a singe impairment has decined. This refects improvements in the prevention and treatment of conditions that have traditionay been known to cause bindness in chidren. An exampe of this is the prompt detection and treatment of ROP (retinopathy of prematurity) in pre-term babies. Improvements in medica care and equipment have aso made surviva possibe for babies who are pre-term or of ow birth weight, those suffering severe birth trauma and others with ife-threatening deveopmenta and genetic conditions. Many of these chidren may respond we to medica intervention and enjoy heathy active ives, but some may have ong term medica compications, earning difficuties, physica and sensory impairments. There is now an awareness that infants and chidren with the most profound areas of need may aso have a significant visua oss and that this wi have an impact on their support requirements. One of the most common causes of bindness in chidren who have compex needs is cerebra visua impairment (CVI). This is damage to the visua-processing area or the visua pathways within the brain. The eyes and optic nerve may be heathy, but the brain is not abe to turn the nerve impuses into meaningfu visua information. Imagine having a webcam that works perfecty, connected to a broken computer that cannot show the images. Other chidren may have a condition that affects the optic nerve, whereby the optic nerve has been irreparaby damaged and cannot transmit signas from the eyes to the brain. Best of both Visua Visua impairment and and physiotherapy 3
Physica deveopment and visua impairment What is the roe of vision in a chid's physica deveopment? A baby s vision deveops graduay in the first year. Let s take Michae as an exampe. He focuses on Mum s face when she feeds him. Soon he wi turn his head to ocate her. Next he wi ook from side to side at famiiar faces and interesting things. When he is paced on his tummy, he wi earn to raise, ift and turn his head to ook a around. Lying on his back, Michae wi watch his hands in midine, experiment with finger movements and manipuate toys to expore them. He wi grasp and study his feet too. Visuay directed arm and eg movements become more accurate as he grasps and kicks at objects he can see. He earns to craw, motivated by his visua interest in things further away. Sitting, standing, cruising, waking, reaching and cimbing are aso driven by visua curiosity, so that independent mobiity is quite we estabished by the end of the first year. How is physica deveopment affected if a chid has a visua impairment? Now consider Lucy, a bind infant. Take away a visua motivation and Lucy is more at risk of deayed gross and fine motor skis such as roing, sitting, standing and reaching out for objects. She may adopt a head down posture and have poor body awareness. When waking, Lucy may adopt an uneven, rocking gait with one foot eading. The incentive and confidence to move in her environment can easiy be compromised as a resut of visua impairment. Our vision has a vita roe in confirming where we are in space. Vision confirms what our baance tes us and stabiises us when our baance is upset. This is the reason we are advised to keep our eyes on the horizon if we are seasick. Our vision can aso trick our sense of baance. We ve a experienced the sense of moving backwards in a car or train when the vehice next to us moves forwards. A roer-coaster simuation at the cinema can even make our stomachs fip whie we sit perfecty sti in the auditorium. Many chidren who have a visua impairment have a very poor sense of baance, so much so that changing from ying to sitting or standing can be distressing. For a bind chid the sensation may be much worse, as they are not abe to use vision to compensate. It is more difficut for a chid who has a visua impairment to understand anguage associated with space, position and movement. We earn terms ike behind, on, under, hop, skip, etc initiay through observing the movements of other peope. The QTVI and physiotherapist can work together to devise aternative incentives to move purposefuy and to deveop body and spatia awareness, movement and anguage through co-active demonstration. 4 Best of both Visua impairment and physiotherapy
How can the physiotherapist and QTVI work together to promote a chid s physica deveopment? Some ways incude: Sharing knowedge about each area of deveopment, to hep each other understand the reationships between vision and movement. Using experience and deveoping strategies to work out ways for the chid to overcome the visua issues impacting on physica deveopment. Exampes might incude providing appropriate visua or auditory stimuation to encourage the chid to raise their head, ro or craw. Setting joint targets so that everyone (parents, schoo staff and others) can work in a consistent way to hep the chid deveop new skis. The effect of physica disabiity on vision We have had a brief ook at the ways in which a visua impairment may affect physica deveopment. Let s consider the vice-versa. Having a severe physica disabiity can have a profound effect on the deveopment of functiona vision, visua access and the roe of vision in earning. In addition, chidren who have cerebra pasy may have particuar probems in visua focussing. This may add a further ayer of chaenge to the deveopment of good vision. Here too, the physiotherapist has a vita roe in understanding and supporting the chid s visua needs. Co-operative probem soving We deveop visua recognition by first noticing something, then ooking more cosey and exporing with our other senses. This information goes into our visua ibrary so we know the same object when we see it again. A chid who cannot move cose to ook and expore reies on others for hep. The foowing exampes iustrate how chidren miss vauabe earning opportunities because they are unabe to access them. Bobby Bobby s physiotherapist returns him to cass in his standing frame and finds a space for him in the group. Everyone is watching Mrs Johnson make bread. Bobby can ony see on his eft side, but his standing frame is positioned so that he can t quite see what Mrs Johnson is doing. Bobby gets bored and starts to shout. He is taken out of the cass so the others can isten. Anya At home, Anya, aged three, enjoys ying under her baby gym which has switches hanging from a frame. She has a good range of movement with her egs and feet and can kick the switches to pay tunes. Today at the nursery, she has a new work chair which enabes her to sit straight, with her head and body we supported and her feet secured in a good position. Anya is paced by the computer and watches the dispay on the screen. She woud ove to touch it, but her chair won t aow her to reach forward. She tries to move her feet, as this usuay gets a resut. Best of both Visua impairment and physiotherapy 5
Her feet are strapped to the footrest. Anya eventuay oses interest and coses her eyes. A member of staff thinks another chid woud get more benefit from the computer and moves Anya away. However, with common sense, good communication and a itte compromise, most access issues can usuay be resoved, as the foowing exampes show. Mohammed Mohammed ies over his wedge to encourage him to raise his head and strengthen his back and neck musces. Visuay, he is aware of ights and refective materias, but unabe to see objects in a norma indoor environment. The QTVI works with Mohammed each week and co-ordinates aternate visits with his physiotherapy session. With the incentive of ights and shiny materias, Mohammed wi attempt to raise his head, thus achieving both visua and physica targets. Afie Afie has a mouded seat in which he is tited back, his egs sighty outstretched. He aso spends some time on the foor, secured in a symmetrica position over his wedge. Afie s teacher wants him to use the computer. He can t get cose enough to the screen in his chair, and is too ow down when using his wedge. The physiotherapist provides a rise and fa bed to use with the wedge. Afie now has good visua access to the computer whie fufiing part of his physio programme. Peter Peter wears gasses and uses hearing aids. He aso needs a headrest to prevent his head fopping sideways. This interferes with his hearing aids and resuts in him hardy ever wearing them. Likewise, his gasses are rarey used as every head movement causes them to fa off. Peter now spends most of the day in virtua isoation. The QTVI discusses this with the physiotherapist who suggests that a neck support used during supervised earning time might achieve the same resut as the headrest without compromising the use of gasses and hearing aids. Maya The physiotherapist recommends that Maya uses her standing frame for certain activities. Maya finds it difficut to toerate this. The QTVI provides some sensory activities to keep the session going. Musica instruments or water pay are interesting enough to make the experience positive. Stuart Stuart has a severe upper visua fied oss. When his head is down on his chest he can ony see his own T-shirt. His cass teacher, QTVI and physiotherapist have worked together to hep him deveop head-contro. When his head is up he is given motivating things to ook at which fa within his reduced visua range. When he gets tired he uses a specia headband on his chair to keep his head in a good mid-ine position, which enabes him to use his vision more effectivey. 6 Best of both Visua impairment and physiotherapy
Equipment and other issues to consider The QTVI appreciates having some input when speciaist equipment is being ordered for a chid. Whie the primary purpose is to address the chid s postura needs, some advice from the QTVI can make a rea difference in terms of visua and sensory access to earning. Using contrast and other features Toys often come in bright coours, so a dark work surface heps provide a good contrast. Trays often come in yeow, which in some (though not a) cases might be the east appropriate in visua terms. A removabe insert in the opposite shade intensity woud be idea to provide good contrast in a situations. Coour contrast issues aso appy to other equipment. For exampe, mats and wedges that bend with the cassroom foor covering might be a tripping hazard for an ambuant chid with ow vision. It is important to make things as easy to see as possibe so consider the size of an object and where it is paced, how good the ighting is and if there is any gare from surfaces. Work trays with raised edges Work chair trays with raised edges and a pain surface are particuary good for chidren who have very ow vision or who are bind as they prevent objects roing off. An integrated bow in a tray is a great asset for sensory work. A tray that tits with the chair instead of remaining eve is often impossibe to use! Many mouded chairs do not have trays fitted. The shape of the chair often prevents a chid s knees fitting under a tabe, making it impossibe for the chid to access anything even a switch! A chidren need access to a soid surface either a tray, or a rise and fa tabe. Other considerations for the QTVI and physiotherapist in reation to chidren with a visua impairment and compex needs How can we improve the range of a chid s arm and hand movements so that they can use their hands to expore? Are there exercises to wake up the hands and improve touch sensitivity? Can a chid sometimes wak without their boots so they can fee the surface of the foor? Arm spints can prevent a chid from exporing their tray. Is there another soution? Where is the best pace to put a switch? If a chid is bind and has hemipegia affecting their eft arm, shoud aduts wak on this side? Or shoud the chid take the arm of their sighted guide with their other hand? What sensory cue or object of reference shoud we use to prepare a chid for their physio session? Teachers and physiotherapists reading this wi think of many more. Best of both Visua impairment and physiotherapy 7
Concusion Both professionas have the same utimate goa to improve the ife of the chid. The physiotherapist works to maintain and improve posture and movement, heping the chid reach their fu potentia. This is vita for quaity of ife and management of care. The QTVI s aim is to promote access to earning, freedom to expore and incusion in a peer group activities. Occasionay ideas and practice wi differ, but through co-operative working the QTVI and physiotherapist can ensure that their shared chidren aways have the best of both. Insight magazine Inspirationa and practica information on the education, heath and webeing of chidren and young peope with visua impairment, incuding those with compex needs. Parents now receive Insight free when they become RNIB Members. Insight is aso now avaiabe free to VIEW members! For detais, ca 0303 1234 5555 and quote Insight offer. Coming soon Into physiotherapy: wecoming and supporting disabed students Owen Hutchinson, Jane and Atkinson, Karen (2010) CSP and RNIB, London This easy-to-use resource, produced by the Chartered Society of Physiotherapy (CSP) and RNIB, aims to wecome and support disabed students into physiotherapy as a career. It offers advice to physiotherapy educators, providing them with genera principes to guide activities as we as information in reation to appications, deveoping poicies and resources incuding guidance for academic staff and practice based educators. Further information on this new resource is avaiabe from the CSP enquiry handing unit on 020 7306 6666. Cover image from RNIB Rushton Schoo and Chidren s Home RNIB November 2010 Registered charity number 226227