Description #

Meet Carl.

He has had very little vision since birth. Carl uses a white cane to help him navigate public spaces and he has an excellent memory to help him remember pathways and routes. At 31 years old, Carl is pretty independent, although he needs support when he is becoming familiar with a new space. Carl is an avid computer user and works in the tech industry. Carl is very good at describing the kind of support he needs to be successful with a new activity.

Meet Jaimie.

She has recently lost her vision due to diabetic retinopathy (she is also diagnosed with Type 2 diabetes mellitus. Jaimie has struggled with healthy lifestyle choices for almost all of her 54 years. As such she is very overweight, smokes regularly, and is new to physical activity. Her doctor has strongly advised her to start exercising to help her manage her diabetes. Jaimie has been struggling to accept her visual impairment and is frustrated with her recent loss of independence.

What do I need to know? #

Visual impairment affects 285 million people internationally. 39 million of these people experience complete blindness and 246 million have partial sight. Approximately 90% of these people live in economically developing countries and approximately 65% over 50 years of age (WHO, 2014).  The International Classification of Diseases (update and revision, 2006) outlines four levels of visual function.

1. Normal vision
2. Moderate visual impairment
3. Severe visual impairment (2+3 = low vision)
4. Blindness (2+3+4 = visual impairment)

Some people are born with a visual impairment, however most people develop their impairment. The main causes of visual impairment are cataracts, macular degeneration and diabetic retinopathy and glaucoma.

Cataract

A cataract is a clouding that covers the eye lens causing vision to become blurry or cloudy and lights can become glaring or may seem too bright. They are the most common cause of blindness across the globe and occur when the protein in the eye lens builds up clouding part of the lens. The cataract continues to grow over time and can eventually cause blindness. Again healthy lifestyle choices can prevent cataracts. For example, a healthy diet and physical activity can support the participant in maintaining healthy blood pressure, weight, blood sugar levels, eating plenty of vegetables and fruit and protecting the eyes from direct sunlight. Click here to see what a participant with cataracts may see

Diabetic Retinopathy

In economically developed countries people with diabetes mellitus type 1 & 2 (DM1 & DM2) are almost twice as likely to experience visual impairments than those without DM2. Diabetic retinopathy is caused by DM1 and DM2 and includes of a range of conditions that all consist of damage to the retina.  In the USA this is the most common cause of visual impairment affecting more than half of those with DM2. 90 percent of visual impairment due to DM2 is preventable by choosing healthy lifestyle choices especially in relation to diet (reducing sugar levels and blood pressure) and physical activity (reducing blood pressure).  There are two main types of retinopathy, non-proliferate and proliferate (proliferate means rapid reproduction of cells).  In the former, the capillaries (tiny blood vessels that transport blood from veins to arteries) swell and form pockets and as more and more of these blood vessels swell the individual moves from mild, to moderate, to severe non-proliferate retinopathy causing blurry vision. Almost everyone who has DM1 and DM2 will get at least a mild version of this. This eventually progressed to proliferate retinopathy as the blood vessels become permanently closed in which case the individual will start to see floating spots which eventually leads to blindness. Click here to see what participants with proliferate retinopathy may see

People with DM2 are also more likely to experience glaucoma (40%) and cataracts (60%) than the general population.

Macular Degeneration

Macular degeneration is mostly an age-related visual impairment that affects central vision making activities of daily living that require fine vision (e.g., reading, driving) difficult. It is caused by the gradual break-down of the macula which is the central part of the retina that is responsible for focusing central vision. Click here to see what participants with macular degeneration may see

Glaucoma

Glaucoma is caused by pressure that builds up in the eyes. This pressure often causes the clear fluid in front of the eyeball (aqueous humour) to build up in the anterior chamber pinching the blood vessels that bring blood to the retina and the optic nerve. This causes damage over time, leading to visual impairment in the form of blind spots that get larger over time, eventually causing blindness. Click here to see what participants with glaucoma may see

The Consultation #

Use the consultation as an opportunity to get to know the participant. In addition to gathering medical information and fitness/ physical activity experience, you can also focus on goal setting and learning about participant preferences. In addition to discussing the exercises themselves, ask the participant about how they will get to the fitness centre, and the level of support they need to access the locker room, and prepare for exercise.

You want to support the participant to be as independent as possible. Depending on the individual, this may change over time as they become more familiar with the setting and feel more confident and capable.

Here are some tips to help you when you meet someone with a VI for the first time:

• Identify yourself when speaking. Don’t assume the person will recognize your voice. For example, the next time you greet the person, you can say, “Hi Sam, it’s Jennifer, how are you doing today?”
• Be yourself- speak naturally and clearly. Just because a person has a visual impariment, doesn’t mean they also have a hearing impairment (or any other kind of disability).
• Continue to use your regular body lanuage while speaking, it will help you to speak naturally and maintain your regular tone of voice
• If other people join the conversation, be sure to introduce everyone
• Don’t leave the conversation or walk away without letting person with a VI know. For example, if you have to go to another room to get a form, be sure to say “I’m stepping out of the room for a moment and will be right back”.
• When giving instructions or directions, be as specific as possible. For example, when leaving the room you can say “The door is on your right” rather than “The door is over there”.
• It’s ok to ask about the kind of assistance they might need- for example- do they need someone to guide them to navigate the building? This might only be necessary for the first few visits. It’s important to ask and encourage open communication as everyone is different and their needs may change over time!

(http://www.visionaustralia.org/services/family-friends-and-carers/communicating-effectively-with-people-who-are-blind)

Implications for Exercise #

For People with visual impairments can experience various levels of impairment and also various levels of inclusion in society and activities of daily living, depending on many environmental (people’s attitudes and the physical environment) and personal factors (motivation, confidence etc). This population are also more likely to have lower levels of fitness that those without visual impairments. Unless the participant has other conditions or impairments that have implications for exercise (in these cases, be sure to see the relevant UFIT Explorer guidelines), the participant will be able to participate in fitness activities once they are guided through the environment and they feel safe.

Participants who are recovering from surgery or who experience glaucoma should always breathe in a slow and controlled manner and avoid high intensity activities and inverted positions in which their head is below their body as this increases the pressure in the eye and can cause permanent damage. Guiding the participant in becoming familiar with the Rate of Perceived Exertion Scale (RPE Scale) will support them with maintaining moderate intensity.

Smiley Face Relative Perceived Exertion Scale

Don’t forget:

Every person is like every other person, like some other person, and like no other person.

Medication & Exercise: What do you need to know? #

Participants will generally not be taking medication for their visual impairment, unless they have recently had eye surgery in which case they may be taking pain medication. However, participants with other conditions and/or impairments may be prescribed medication for that. In this case, see the UFIT Explorer guidelines for that condition and check whether the medication has any implications for exercise

Inclusive TIMES: Tips & Strategies for Individuals with visual impairment #

The tips and strategies found within the inclusive TIMES section will help you to create an environment that will support your participant’s participation in physical activity as independently as possible. It is important that you involve the participant whenever possible, along the way to ensure the program that you design will meet their needs physically, as well as emotionally and socially. Introducing a few simple strategies such as offering visual images of the participant’s program will help them to be more independent in completing their fitness programme. Ultimately, they will gain confidence and belief in their abilities (increasing self-efficacy) and experience self-determination (sense of control over their own destiny). This is key to establishing healthy habits that will be adopted for the long term.

Time #

• Some participant’s visual impairment may be worse at certain times of the day, for example when the sun is strong or in the dark. In these cases, exercising outside of these times of day will support the participant.

Instruction #

• The following YouTube video by Perkins School for the Blind offers excellent guidance on working with children with visual impairments that can be applied to the fitness environment https://www.youtube.com/watch?v=77fyMsRWrYs
• Plenty of verbal cues will support participants with visual impairments while also giving demonstrations when the participant has some vision. Remember that the participant may not have a concept of what an activity involves unless they have participated in it previously.
• Tactile modelling of an environment can be created on boards to allow the participant get a feel for the environment in which they will be exercising. Ideally there would be a tactile map of the facility near the entrance and also a model of each fitness room. Fitness professionals could also create tactile models of circuits and other group and one-to-one sessions. These boards are ideally supported with a walk-through of the area before the session starts (go to 5:25-5:57 and 9:22-10:19 of video).
• Whole-part-whole instruction method is one of the most successful methods for participants with visual impairments. It explains the entire activity at the beginning to provide the participant with an understanding of the whole activity and how the skill or part of the activity they are learning fits within the whole activity. For example, when a participant is learning to swim, the instructor would ask them to attempt the front crawl if they have some experience swimming. The instructor would then give them instruction on any points that could be improved, e.g., six lengths of leg kick holding a float, and then followed by six lengths of front crawl with the improved leg kick. For complete beginners this method requires creativity when finding a way to explain the whole activity. Tactile modelling, verbal explanation and task analysis may be used (go to 6:41 of video).
• Co-active movement is similar to tactile modelling except the participant experiences the whole movement. The participant’s moving body part touches the instructor’s moving body part (go to 10:24 of video).
• Physical guidance may be necessary when tactile modelling, verbal demonstration and coactive movement will not work. When this type of instruction is being used, it is very important to speak with the participant about it beforehand and to be mindful to always move with the participant while giving plenty of verbal cues to ensure that they feel safe, secure and in control (go to 11:19 of video).
• Task analysis is the breakdown of a skill into smaller chunks in a series and so the entire skill is learned in a progression. Verbal instruction, tactile modelling and physical guiding are all used to support the participant (go to 8:18 of video)

Movement #

• Some participants may not require guiding if they have some sight and are very familiar with the environment. Other participants may require guiding at all times or in certain situations (go to 2:38-5:23 of https://www.youtube.com/watch?v=77fyMsRWrYs)
• Human guide: guide offers the participant their elbow which they hold with their thumb pointing outwards. The guide’s responsibility is to verbally cue the participant when there are changes in terrain e.g., “upcoming stairs, with a handrail on the right. step up”, “door opening on the right”.

Guided running:

• Running with a guide-wire in a line: a rope is tightly pulled across the running space (gym, track etc) with a handle or carabiner on the rope for the participant to hold as they run. There should be a clear marker towards the end of the line indicating the end of the rope.
• Running with a guidewire in a circle: 30ft rope is anchored to a point (eg. a large stake in grass) and the participant runs in a circle around this point. A radio or metronome can be used to allow the participant to know where they started.
• Auditory running: a participant runs to a caller; or to a sound with a runner running ahead of them.
• Running on a treadmill: ensure controls are clearly marked and tactile to facilitate independence.
• Running with a guide: It is important that the guide runner is faster than the participant. The participant holds guide’s elbow (or shoulder if the guide is shorter than them) as in human guide technique. While running both runners can swing their arms.
• Running with a guide using a tether: It is important that the guide runner is faster than the participant. The guide and participant both hold either end of a tether (short rope, shoe-lace or towel). While running, both runners can swing their arms.
• For participants recovering from eye surgery and those with glaucoma, even if they don’t experience a visual impairment, should avoid very high intensity activities, holding their breath during resistance training and inverted positions (their head is below their body) as they cause the fluid pressure in the eye (intraocular pressure) to increase which can cause permanent damage. E.g., handstands, yoga positions like downward dog.
• Allow participants to start off at low intensity until they feel more confident within the environment and as they move through the space.
• Introducing the RPE Scale is important, especially for those with glaucoma and recovering from eye surgery as high intensity activities should be avoided (they can increase pressure in the eye)
• To build self-efficacy of movement and physical activity, basic proprioception and balance exercises can be introduced and gradually progressed. For example, once a participant can do a squat you can progress to arms overhead → wobble board → one-legged squat.

Environment #

• Ensuring the environment is safe is the main priority for participants with visual impairments. It is important that there are no overhanging shelves that participants using walking canes may not perceive.
• Provide all participants with visual impairments with a walk-through of the facility during their consultation.
• Allow the participant to feel all equipment before using it.
• In group sessions, invite participants with visual impairments to arrive a little early to provide them with an overview and walk through of the session before starting.
• If the participant is sensitive to sunlight and/or glare, ensure that they are protected from these. For example, when exercising outdoors, sunglasses and hats can be worn and when exercising indoors, ensuring that the participant is not facing a window.
• People with visual impairments will generally find modern touch-screen equipment difficult to use unless the machinery responds to voice activation. Generally, equipment with raised buttons is more suitable and discreet.
• Equipment that makes sound can be used to support participants. For example, bell balls or beepers can be fitted to equipment or stations (clapping also works!)
• A guide-wire to mark the perimeter of a track, circuit or other type of exercise space can assist the participant in moving independently throughout the session.
• Tactile markings and large print on signage can be used to identify objects and spaces within the environment.
• When participants have some vision, bright colours and flags are supportive to indicate exercise stations, swimming and running lanes, heights, steps etc.
• Participants may wear vibrating or beeping timers to keep track of time.
• As much as possible, keep equipment, furniture, and machines in the same place- this will help participants to navigate the space more independently and feel comfortable when they come back for the next session

Support #

• Provide a variety of activities at the beginning of the programme, allowing the participant to rate their level of enjoyment and the likelihood of them choosing each activity on a regular basis.
• To introduce the RPE Scale, you can talk about, then begin to exercise, repeating the various levels and asking them to gauge where they are on the scale. This should be repeated in each session until they are familiar with the scale.
• Depending on the level of their impairment and their level of independence, some participants may be supported by a guide-dog or friend. If supported by a friend, this may be done by an elbow lead, a tether or in running activities by following a guide who is wearing brightly coloured clothes.
• The greatest personal barriers for participants with visual impairments can be fear and a lack of confidence. Exploring the participant’s fears with them and guiding them in identifying ways in which they can practically overcome these fears will greatly support the participant and also help build a relationship of trust which will increase the participant’s adherence to the programme.
• To support participants with some vision, use a clear, simple font on all information, marketing and promotional materials.

References #

Aillaud, C., & Lieberman, L.J. (2013), Everybody plays: How children with visual impairments play sports, Louisville, KY: American Printing House for the Blind

American Academy of Ophthalmology, (2013), Cataract Vision Simulator, available at: http://www.aao.org/eye-health/diseases/cataracts-vision-simulator [accessed 27th August 2016]

American Academy of Ophthalmology, (2013), Glaucoma Vision Simulator, available at: http://www.aao.org/eye-health/diseases/glaucoma-vision-simulator [accessed 27th August 2016]

American Academy of Ophthalmology, (2013), Macular Degeneration Vision Simulator, available at: http://www.aao.org/eye-health/diseases/amd-vision-simulator [accessed 27th August 2016]

American Academy of Ophthalmology, (2013), Proliferative Diabetic Retinopathy Vision Simulator, available at: http://www.aao.org/eye-health/diseases/proliferative-diabetic-retinopathy-vision-simulato [accessed 27th August 2016]

Exercise is Medicine, ‘Your Prescription for Health Series’, available at: http://exerciseismedicine.org/assets/page_documents/YPH_All.pdf [accessed 6th April 2016]

Garden-Robinson, J., Stastny, S., Kjera, K., McNeal, K. and Wang, S., (2013), ‘Cooking and Eating with Low Vision’, available at: https://www.ag.ndsu.edu/vision/presentations/CookingandEatingLESSON.pdf [accessed 112th November 2016]

Green, J., (2012), ‘Guidelines for Trainers with Participants with Visual Impairments’, NCHPAD, Available at: http://www.nchpad.org/838/4261/Guidelines~for~Trainers~with~Participants~with~Visual~Impairments [accessed 20th August 2016]

Harvard School of Public Health, ‘Healthy Eating Plate & Healthy Eating Pyramid’, available at: https://www.hsph.harvard.edu/nutritionsource/healthy-eating-plate/ [accessed 9^th May 2016]

Lieberman, L.J, (2002), ‘Fitness for Individuals who are Visually Impaired or Deafblind’, RE:View, 34, 1 available at: http://www.aph.org/physical-education/articles/fitness-for-individuals-who-are-visually-impaired-or-deafblind/ [accessed 20^th August 2016]

Lieberman, L.J., & Cowart, J., (2011), Games for people with sensory impairments (2nd ed.). Louisville, KY: American Printing House for the Blind

Lieberman, L.J., Haibach, P., (2016), Motor development for children with visual impairments. Louisville, KY: American Printing House for the Blind

Lieberman, L.J., Haegele, J.A., & Marquez, M., (2015), Possibilities: Recreation experiences of individuals who are deafblind, (e-book) Louisville, KY: American Printing House for the Blind

Lieberman, LJ., Modell, S., Ponchillia, P., Jackson, I., (2006), ‘Going Places: Transition Guidelines for Community-based Physical Activities for Students who have Visual Impairments, Blindness or Deaf-bllindness’, American Printing House for the Blind, available at http://www.aph.org/files/manuals/Going-Places.pdf [accessed 14th November 2016]

Lieberman, L.J., Ponchillia, P., & Ponchillia, S., (2013), Physical education and sport for individuals who are visually impaired or deafblind: Foundations of instruction, New York, NY: American Federation of the Blind Press

Medicine Plus, (2008), ‘Leading Causes of Blindness’, Medicine Plus – Summer Issue, 3, 3, 14-15 https://medlineplus.gov/magazine/issues/summer08/articles/summer08pg14-15.html

Moore, G., Durstine, L., and Painter, P., eds. (2016) American College of Sports Medicine: Exercise Management for Persons with Chronic Diseases and Disabilities, 5^th Edition, Human Kinetics, Champaign

Pescatello, L., Arena, R., Riebe, D., Thompson, P., eds. (2014), ACSM’s guidelines for exercise testing and prescription, 9^th Edition, Baltimore: Lippincott Williams & Wilkins

Swain, D., Brawner, C., Chambliss, H., Nagelkirk, P., Paternostro Bayles, M. and Swank, A., eds. (2014), ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription, 7^th Edition, Baltimore: Lippincott Williams & Wilkins

Vision Australia Austrailian (n.d). Communicating effectively with people who are blind. http://www.visionaustralia.org/services/family-friends-and-carers/communicating-effectively-with-people-who-are-blind [Accessed 26th July 2017]

WHO Global Action Plan 2013-2020, available at: http://apps.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.pdf [accessed 12th July 2016]

WHO, (2014), Visual Impairment and Blindness, available at: http://www.who.int/mediacentre/factsheets/fs282/en/ [accessed 28^th July 2016]

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