Article
Journal of VisualImpairment & Blindness2021, Vol. 0(0) 1–13© American Foundationfor the Blind 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/0145482X211027491journals.sagepub.com/home/jvb
Effects of a Physical TherapyIntervention to Improve theQuality of Life of VisuallyImpaired People: Developmentof an Audio–Tactile ExerciseProtocol
Maristella Borges Silva1, Suraya Gomes Novais Shimano2,and Nuno Miguel Lopes de Oliveira2
AbstractIntroduction: The purpose of this study was to develop and implement an audio–tactile protocolfor therapeutic intervention in individuals with visual impairments.Methods: The PhysiotherapyProtocol for People with Visual Impairment (PP-PVI) was developed following five steps:physiotherapy evaluation, linguistic selection, protocol design, linguistic adequation for visuallyimpaired, and linguistic adequation for English language. Three adolescents and three young adultswith visual impairments participated in this longitudinal study and performed the protocol oftherapeutic exercises twice a week for 12 months while being evaluated with respect to theirquality of life before and after. The quality of life was evaluated using the 36-item Short FormHealth Survey (SF-36). Results: The median score for all domains of the quality of life ques-tionnaire improved after PP-PVI, with the exception of the body pain domain, which remainedunchanged. Discussion: The PP-PVI was shown to be an important method of therapeuticintervention, and it was easy to understand and apply in persons with visual impairments.Implications for practitioners: The exercises of the PP-PVI facilitate the development ofseveral physical and functional capabilities that are important to the independence of individualswith visual impairments.
Keywordsvisual impairment, physical therapy modalities, quality of life, sedentary lifestyle
Visual impairment (i.e., blindness or low vi-sion) is assessed by two parameters, visualacuity (what is seen at a given distance) andvisual field (area reached by vision). Blindnessis classified as a visual acuity of less than 0.05or a visual field of less than 10°. Low vision isclassified as a visual acuity less than 0.3 andgreater than or equal to 0.05 or a visual fieldof less than 20° in the best eye with the best
1Department of Health, Faculty of Human Talent, Uberaba,Minas Gerais, Brazil2Department of Applied Physiotherapy, Federal Universityof Triangulo Mineiro, Uberaba, Minas Gerais, Brazil
Corresponding author:Maristella Borges Silva, Department of Health, Facultyof Human Talent, Av. Tonico dos Santos, 333, Uberaba38040-000, Minas Gerais, Brazil.Email: maristellaborges@gmail
optical correction (Bourne et al., 2017; Ottaiano,Avila, Umbelino, & Taleb, 2019). Low vision isfurther subdivided into mild, moderate, orsevere/profound, depending on the degree ofvisual impairment (ICD-10-CM Codes H54)(WHO, 2019).
Vision is considered a major facilitator ofthe integration of motor, perceptual and mentalactivities. Therefore, its deprivation in the sen-sory function may cause functional limitations(Saydah, Gerzoff, Taylor, Ehrlich, & Saaddine,2019). Individuals with visual impairmentsexhibit functional impairments or physicallosses related to the deficit of static and dy-namic balance (Horak, Wrisley, & Frank, 2009;Machado, Oliveira, Urquizo, Shimano, &Oliveira, 2019; Parreira, Grecco, & Oliveira,2017; Rutkowska et al., 2015). Moreover,postural changes can lead to other disabilitiessuch as loss of flexibility, cardiorespiratoryfitness, or muscle strength and decreased mo-tor coordination and body awareness (Aslan,Calik, & Kitis, 2012; Rutkowska et al., 2015;Silva, Shimano, Oliveira, Conti, & Oliveira,2011). Furthermore, individuals with disabil-ities have shown increased sedentary behav-iors and more precarious levels of physicalfitness (Cervantes & Porreta, 2010). Physicalinactivity worldwide is an important healthissue for individuals with visual impairments(Starkoff, Lenz, Lieberman, & Foley, 2016).
In general, vision loss can cause psycho-logical, social, economic, and physical functionproblems, resulting in a negative effect on thequality of life of the individual. It often in-volves a loss of self-esteem and social status,gradual impairment of motor and functionalskills, as well as occupational restrictions and,consequently, a decrease in household income(Becker & Montilha, 2015; Brian et al., 2019;Elsman, van Rens, & van Nispen, 2017;Rainey, Elsman, van Nispen, van Leeuwen, &van Rens, 2016).
Physical therapy modalities play a signifi-cant role for people with visual impairments;interventions for health and wellness for thispopulation can be targeted to acquire and im-prove autonomy, mobility, motor coordination,balance, body awareness, laterality, body posture,
flexibility, muscular strength, cardiovascularconditioning, and general health improvement(van Leeuwen, Rainey, van Rens, & vanNispen, 2015). Children with visual impair-ments have difficulties with locomotor skills;for this, they need a valid intervention thatprepares them for daily demands (Brian et al.,2019, 2020).
The challenge of a specific therapeutic ap-proach for people with visual impairments is toensure the learning of each proposed inter-vention. In physical therapy intervention, themain objective is to guarantee independence inthe correct execution of each movement so thatthere is the gain of physical and functionalskills and capabilities that are essential for goodmotor performance. This motor learning pro-cess for individuals with visual impairmentscan be promoted if the senses of hearing andtouch are prioritized as a learning method(Alary et al., 2009; Joshi, Ray, Odierna &Smith, 2019; Urquizo, 2018).
In this context, audio–tactile protocols maybe an appropriate strategy for health inter-vention. The linguistic construction of verbalcommands becomes essential not only to un-derstand the objectives of each exercise pro-posed but also to perform each movementcorrectly. In addition to verbal commands,tactile commands must be precise and objec-tive, correcting postural errors during theperformance of movements. These two com-mands should be designed to be applied simul-taneously. Therefore, the development processof an audio–tactile protocol requires a cohesiveteam that includes professionals from differentareas of health and education. For this reason,the fulfillment of health promotion approachesfor people with visual impairments is a chal-lenge because there are few adapted physicalexercises protocols for these individuals thatallow for the enhancement of their physicaland functional conditions, social interactions,and, ultimately, improvement of their qualityof life.
The purpose of this study was to developand apply an audio–tactile protocol for healthpromotion intervention in individuals withvisual impairments. Therefore, the linguistic
2 Journal of Visual Impairment & Blindness 0(0)
construction of verbal and tactile commandswas accomplished by a team of experiencedvisual impairment professionals. Individualswith visual impairments performed the exer-cises in the protocol for an extended period,and they were evaluated with respect to theirquality of life before and after. We hypothe-sized that a specific protocol for individualswould facilitate their learning of new thera-peutic exercises and improve their overallhealth and quality of life.
Methods
Participants
Three adolescents and three young adults withvisual impairments participated in this longi-tudinal study; they were treated at the BrazilianMid-West Institute for the Blind (ICBC) inUberaba, Minas Gerais, Brazil. This study wasdedicated to develop and apply a therapeuticexercise protocol, and it was approved by theResearch Ethics Committee of the FederalUniversity of Triangulo Mineiro, Brazil (pro-tocol 1965) and registered on the BrazilianClinical Trials Registry (number: RBR-2ssg4w).Convenience sampling was performed over3 weeks, in which a screening process es-tablished the following inclusion criteria: in-dividual with blindness or low vision; agedbetween 18 and 59 years; cognitive autonomyassessed by the cutoff points of the Mini-Mental State Examination (Brucki, Nitrin,Caramelli, Bertolucci, & Okamoto, 2003);and no neurological, cardiac, or disablingmusculoskeletal diseases. Exclusion criteriawere missing three or more consecutive ses-sions of physiotherapy or missing five sessionsduring the period of the protocol performanceor both. Furthermore, participants who clearlyhad difficulties understanding the question-naire at any point of the study were excluded.Following examination of these criteria, 10individuals were included and four were sub-sequently excluded. Thus, only six individualswith visual impairments were effectively ana-lyzed in this study. Participants were verballyinformed about the intention and procedures
of the study and provided informed consent.This study was conducted in the physiother-apy room at the ICBC, with appropriate ma-terials and equipment for assessments andinterventions.
Development of the protocol
The development of the Physiotherapy Proto-col for People with Visual Impairment (PP-PVI)followed these five steps: (1) physiotherapyevaluation, (2) linguistic selection, (3) protocoldesign, (4) linguistic adequation for peoplewith visual impairments, and (5) linguisticadequation for the English language.
Step 1. Initially, a physiotherapy evaluationwas performed to characterize the sample inorder to guide the protocol development. Forthis reason, all participants responded to an oralquestionnaire about their data and diagnosis ofvisual impairment. Data files of ICBC werealso analyzed to confirm the information pro-vided, as well as to compile further relevantdata. Subsequently, physical therapy evalua-tions were performed, including anamnesis,vital data, anthropometric measurements, classicpostural assessment, and evaluations of strengthand flexibility. In addition, quality of life wasevaluated through a fair reading of the 36-itemShort Form Health Survey (SF-36) becausemost participants did not read braille. The SF-36 questionnaire was validated for Portuguese(Ciconelli, Ferraz, Santos, Meinão, &Quaresma,1999), and it is a tool that is designed to assesshealth-related quality of life. It is composedof 36 items distributed among eight domains:physical functioning, role limitations due tophysical health problems, body pain, generalhealth perceptions, vitality, social function-ing, role limitations due to emotional prob-lems, and general mental health. The final scoreranges from 0 (worst) to 100 (best) for eachdomain.
Step 2. Three physical therapists who had workexperience in visual impairment (throughcourses in adapted pedagogy, assistive tech-nology, and special education) and a young
Borges Silva et al. 3
woman with blindness who was a physio-therapy undergraduate student conducted asurvey of words or terms commonly used todescribe the exercises.
Step 3. The choice of exercises to be includedin the protocol was based on the results ofphysical evaluations. The specific aims to beachieved were improving mobility, musclestrengthening, flexibility, and posture, withemphasis on the most important impairmentfinding, which was decreased flexibility. It wasconsidered an intervention of approximately40 minutes, with a total of 13 exercises in-cluded in the protocol, in which two exerciseswere selected for mobility, four for musclestrengthening, six to increase flexibility, andone exercise to effect global postural reedu-cation. Verbal and tactile commands werecreated for each exercise to ensure correctexecution. Each exercise also received a spe-cific name. Therefore, after the learning phase,the physiotherapist could call out the exercise’snames, and the individuals with visual im-pairments would be able to perform the exer-cise with autonomy.
Step 4. The verbal and tactile commands werecreated with the participation of a physiother-apy undergraduate student who was blind. Twoparticipants with visual impairments performedthe exercises according to the verbal and tactilecommands, and they described the difficultiesin understanding some terms. These terms wererevised accordingly, and the exercise protocolwas retested. In addition to the linguistic ad-justment, some unknown concepts or terms hadto be explained in detail. They were requiredfor the performance of the exercises and couldnot be replaced. For instance, the volunteers didnot know the term analog clock, only the termdigital watch.
Step 5. The participants were instructed inPortuguese. After instruction, the linguisticadjustment of the protocol into English followedtwo stages. The first was the translation of theprotocol by a native Brazilian with expertise inthe English language. The second step was the
revision of the translation by a native Englishspeaker with expertise in linguistics.
Following these five steps, the theorical partof PP-PVI was completed (see Table 1). Thus,its application and the evaluation of its effectsbegan.
Protocol application
The protocol was carried out twice a week for12 months, although there was a 1-month breakin the middle of this period due to a holidaybreak at the institution. Each session lasted40 minutes and consisted of 5 minutes ofwalking as a warm-up, followed by 30 minutesof the exercise protocol performance and5 minutes of relaxation, which included dia-phragmatic breathing exercises and passivemovements. Every session included music thatwas played in the background that varied ac-cording to the type of exercise. The materialsused during the sessions were sleeping mats,elastic bands, plastic balls (30 cm in diameter),and a stereo system.
To evaluate the effects of this protocol onquality of life, all participants were evaluatedbefore and after this period using the quality oflife questionnaire (SF-36) conducted by thesame evaluator.
Data analysis
The Shapiro–Wilk test showed non-normaldata. Descriptive statistics (median, maxi-mum, and minimum values) and inferentialanalysis (Wilcoxon signed-rank Test) werebased on the scores of the SF-36 questionnairebefore and after the period (12 months) of thephysiotherapy intervention. Statistical analyseswere carried out using the Statistica Package10.0, with a significance level of .05.
Results
The protocol was applied on six individualswith visual impairments. Table 2 shows themain characteristics of the participants. Themeanage was 19.8 ± 5.5 years, four of them werewomen and two were men. Three participants
4 Journal of Visual Impairment & Blindness 0(0)
Tab
le1.
PhysiotherapyProtocol
forPeop
lewith
VisualImpairment.
Finality
Exercise
Objective
Verbalcom
mand
Tactilecommand
Mob
ility
1“Pelvicclock”
Togain
mob
ility
ofthepelvicgirdle
Lieon
your
back
andpressyour
buttocks
andback
againstthe
stretcher.Im
aginethat
your
pelvis
hasthehand
sof
aclock.
Now
positio
nyourselfat12
o’clock.Goo
djob!Now
at6o’clock...no
w3o’clock
(the
watch
concepthasbeen
previouslytaught).
Repeateach
move10
times
The
physiotherapistplaces
his/herhand
ontheiliac
bone
anddirectsthe
movem
ents
indifferent
directions
2“Squ
eezing
clothes”
Togainmob
ility
ofscapular
andpelvicgirdles
Lieon
your
back.T
akeadeep
breath
andbreatheou
tslowly.N
ow,imagine
that
your
body
isapieceof
wet
clothing
you’re
goingto
wring
(out).
Holdyour
kneesw
ithandtryto
make
them
touchthefloo
r.Keepfocused
andkeep
your
rightshou
lder
onthe
stretcher.Dono
tliftyour
shou
lder.
Cou
ntto
10,and
stretchou
rlegs
again.
Switchsidesanddo
the
exercisesagain.
Repeatthemovefive
times
oneach
side
The
physiotherapistshou
ldguidethe
movem
entandkeep
thecontralateral
shou
lder
supp
orted
Muscle
strength
3“T
hebridge”
Toenhancebo
dyaw
arenessandstrengthen
glutes
andabdo
minalmuscles
Lieon
your
back,w
ithbo
thkneesbent
andfeet
flat
onthestretcher.Takea
deep
breath.A
syoubreatheou
t,try
toliftyour
pelviskeepingyour
feet
andshou
ldersflat
onthestretcher.
Now
stay
onthispo
sitio
nandexhale.
Makesure
thepatie
ntisalignedto
avoidlumbarlordosis.
Repeatthismove10
times
The
physiotherapistplaces
his/herhand
ontheindividu
al’sabdo
men
andasks
theperson
toraisethepelvis.A
fter
expiratio
n,thetherapistpu
tshis/her
hand
ontheindividu
al’slumbarspineto
supp
ortthefinalm
ovem
ent (continued)
Borges Silva et al. 5
Tab
le1.
(con
tinued)
Finality
Exercise
Objective
Verbalcom
mand
Tactilecommand
11“Bird-do
g”Togain
strength
oftheextensor
muscles
ofthespine;to
trainbalance;andto
gainbo
dyaw
areness
Positio
nyourselfon
thefloo
ron
your
hand
sandknees.Im
agineado
gthat
willchange
into
abird.S
tretch
one
arm
infron
tof
you,
extend
the
oppo
site
legho
ldingitparalleltothe
floo
r.Cou
ntto
10.N
owsw
itchlegs.
Repeatthemoves
with
both
legs
and
arms10
times
The
physiotherapistshou
ldpo
sitio
nthe
arm
andlegthat
willbe
stretched,
prom
otingabalance
12“C
razy
bike”
Totrainmotor
coordinatio
nandto
develop
strength
oftheabdo
minalmuscles
and
upperandlower
limbs.C
ardiorespiratory
training
andmotor
coordinatio
n
Lieon
your
back.L
iftbo
thlegs
andtry
toride
astationary
bike—
youhave
certainlydo
nethisbefore!K
eepyour
abdo
men
tight
while
cycling.Atthe
sametim
e,raiseon
earm
aboveyour
head
while
loweringtheotherarm,
switching
sides.
Five
sets
of3minutes
with
a30
-second
rest
betw
eensets
The
physiotherapistshou
ldtouchtheleg
tobe
pulledalon
gwith
the
contralateralarm
sothattheindividu
alun
derstand
sthat
theup
perlim
bsand
thelower
limbs
perform
alternate
moves
13“Imaginary
chair”
Tocontrolposture;togainbo
dyaw
arenessin
sittingandstanding
positio
ns;totrain
breathing;andto
gain
musclestrength
ofthelower
limbs
Standback
tothewall.Goo
dJob!
Breatheinandfillyour
stom
achwith
air.Veryslow
ly,slideyour
back
down
thewallasifyouweretrying
tosit
down.
Rolld
ownun
tilthejoints
ofyour
hips,knees,and
heelsform
edan
angleof
90°.I’lltellyou
whenyou’ve
reachedtherightangle.
Right
there!
Great!N
owbreatheinagainandrise
asyouexhale.
Take5breathswith
thefull
movem
ent
The
physiotherapistshou
ldensure
the
supp
ortof
hips
andshou
ldersagainst
thewall,stimulatingtheabdo
minaland
quadriceps
contractionandensure
the
correctdegree
ofknee
flexion
(continued)
6 Journal of Visual Impairment & Blindness 0(0)
Tab
le1.
(con
tinued)
Finality
Exercise
Objective
Verbalcom
mand
Tactilecommand
Flexibility
4“Ballo
nthe
foot”
Todissociate
thescapular
andpelvicgirdle;
andto
increase
theflexibility
ofthe
posteriormuscles
ofthethighandleg
Standtallwith
back
straight.Inh
aleand
liftyour
armsas
high
aspo
ssible
holdingthisballin
your
hand
s.Now
,exhaleas
youbringtheballto
touch
your
rightfoo
t.Goo
djob!Repeatthe
movem
entwith
theleftfoot.
Repeatthemovefive
times
oneach
side
The
physiotherapistshou
ldhittheball
abovetheindividu
al´s
head.T
hiswill
encouragetheperson
tobringtheball
tohis/herfoot.A
tthesametim
ethetherapistshou
ldensure
that
theindividu
alkneesarestretched
astheballtouchesthefoot
5“Foo
ton
the
ball"
Todissociate
thescapular
andpelvicgirdle;
toincrease
theflexibility
ofthepo
sterior
muscles
ofthethighandleg;andto
train
balanceandmotor
coordinatio
n
Standtallwith
back
straight.Inh
aleand
liftyour
armsas
high
aspo
ssible
holdingthisballin
your
hand
s.Now
,exhalewhilebringing
your
rightfoot
totouchtheballat
waist
height.
Now
,dotheotherside.
Repeat10
times
oneach
side
The
physiotherapistshou
ldhittheball
abovetheindividu
al’shead
anditwill
bean
encouragem
entto
take
theball
tohis/herfoot.A
tthesametim
ethetherapistshou
ldensure
that
theindividu
alkneesarestretched
astheballtouchesthefoot
6“Balletinalying
positio
n”
Toincrease
flexibility
ofthemuscles
ofthepo
steriormusclechain
Lieon
your
back
andloop
thestrap
arou
ndtheballof
your
foot
holding
theends
ofthestrapwith
both
hand
s.Be
sure
tokeep
your
chin
downand
shou
ldersback.Exh
alewhilepu
shing
your
heelup
towardtheceiling.K
eep
your
kneesstretched.
Repeatthe
movethreetim
eson
each
side
The
physiotherapisthelpstheindividu
alplacingtheband
arou
ndhis/herfoot
andcorrectin
gthepo
sturedu
ring
theexercise
7“C
urly”
Toincrease
flexibility
ofthemuscles
ofthethoracicandlumbarspine
Lieon
your
back.T
akeadeep
breath.
While
breathingou
t,bend
oneleg
over
your
torso,ho
ldingitjustbelow
theknee.H
oldthispo
sitio
nfor
30second
s.Repeatthemoves
threetim
eson
both
sides
The
physiotherapistcorrects
posture,
thepo
sitio
nof
thehead
andback
ifnecessary
(continued)
Borges Silva et al. 7
Tab
le1.
(con
tinued)
Finality
Exercise
Objective
Verbalcom
mand
Tactilecommand
8“Playing
stork”
Toincrease
flexibility
ofhipflexorsmuscles
andknee
extensorsandto
trainbalance
andprop
rioceptio
n
Standtallwith
back
straight.Be
ndthe
leftlegback
towardyour
buttocks
andho
ldyour
leftfoot
with
your
left
hand
.Keepyour
body
straight
anddo
notmoveto
thesides.Holdthis
positio
nfor30
second
s.Repeatthemoves
with
both
legs
threetim
es
The
physiotherapistcorrectspo
stureand
preventscompensationforthecorrect
executionof
themovem
ent
9“Ear
onthe
shou
lder”
Toincrease
flexibility
ofneck
muscles
Startin
asittingpo
sitio
n.Takeadeep
breath.H
oldon
ehand
againstthe
side
ofyour
head.T
iltyour
head
sideways,so
thatyour
earmay
touch
your
shou
lder.B
reathe
outslow
ly.
Switchto
otherside.
Repeatthe
movethreetim
eson
each
side
The
physiotherapistassiststheindividu
alinkeepingthecorrectpo
sitio
nforthe
exercisesandreminds
theindividu
alno
tto
raisehis/hershou
lders,by
touching
them
Posture
10“Frogon
the
floo
rwith
open
arms”
Toincrease
flexibility
ofthediaphragm,
sterno
cleido
mastoid,scalene,intercostal,
lower
back
muscles,p
ectoralis
major
and
minor,and
theiliop
soas
muscles;togain
strength
ofabdo
minalmuscles,rho
mbo
ids,
quadriceps,and
core
muscles;and
togain
body
awareness
Lieon
your
back
andkeep
your
arms
open.T
hekneesareflexed
andthe
feet
aretogether.F
eelyou
rentire
spinepressing
againstthestretcher
andimagineastraight
linestartin
gat
thecenter
ofyour
head
until
your
buttocks,asifyouwantedto
stretch
it.Goo
djob!Takeadeep
breath
until
your
belly
isfull.Now
very
slow
lyreleasetheairthroughthemou
th,
expelling
allthe
air,andimaginethat
youarepu
lling
your
belly
button
intowardthefloo
r.Takefive
breathswith
thefull
movem
ent
The
physiotherapistshou
ldavoidthe
individu
alliftin
ganypart
ofhis/her
body.T
hetherapistshou
ldalso
compresstheabdo
minalmuscles
sothat
theperson
feelsthecontraction
during
expiratio
n
8 Journal of Visual Impairment & Blindness 0(0)
had profound low vision and three of themwere blind, according to the medical records ofthe institution’s ophthalmologist. The causes ofvisual impairment were varied (see Table 2).
The results of the SF-36 health survey be-fore and after the completion of the PP-PVI arepresented in Table 3. After the implementationof the exercise protocol, the median score forall domains increased, demonstrating an im-provement in the participants’ health outcomes,although the domain to do with body painremained unchanged. The statistical analysisshowed no difference in any SF-36 domainsbefore and after the PP-PVI intervention (sig-nificance level of .05).
Discussion
The steps to create the protocol were definedconsidering the clinical and functional condi-tions of the sample and the educational re-quirements for learning physical exercises. Thephysiotherapy evaluation aimed to measure the
physical impairment of each individual in orderto trace a profile of the group with visual im-pairments and guide the protocol development.From this physical and functional diagnosis,the choice of each therapeutic exercise wasbased not only on the clinical goal but also onthe cognitive-motor learning process of peoplewith visual impairments. Therefore, extensiveresearch of scientific evidence on the types ofexercises specific to physical and functionaldeficits was conducted.
Notably, the focus of the exercise protocolwas to provide an effective and achievableexercise alternative that would change thesedentary lifestyle of these individuals. Thus, alexical analysis was performed with the par-ticipation of pedagogues who specialized invisual impairment. According to each exercisethat would be taught, this group of profes-sionals defined what would be the best words(verbal commands) in the Portuguese languagefor a detailed description of the positioning andthe way to accomplish the exercise. In addition,
Table 2. Characteristics of the participants.
Subject Sex Age in years Visual impairment Cause
1 Female 15 Blindness Acquired (incubator)2 Female 16 Profound low vision Congenital (toxoplasmosis during pregnancy)3 Female 16 Blindness Leber’s congenital amaurosis4 Female 29 Profound low vision Retinitis pigmentosa and cataracts5 Male 19 Blindness Retinal detachment6 Male 24 Profound low vision Incomplete cornea and retinal disorder
Table 3. Median score (minimum and maximum) of the SF-36 quality of life survey before and afterintervention.
Domain Before After p-value
Physical functioning 80 (45; 100) 85 (55; 100) .92Role limitations due to physical health problems 50 (25; 100) 87.5 (50; 100) .06Body pain 86 (40; 100) 86 (22; 100) .59General health perceptions 62 (50; 90) 74.5 (57; 92) .67Vitality 57.5 (30; 95) 80 (50; 100) .17Social functioning 56.2 (25; 100) 62.5 (12.5; 100) .78Role limitations due to emotional problems 33.3 (0; 100) 66.7 (0; 100) .36General mental health 54 (28; 72) 68 (32; 100) .06
p-value: Wilcoxon test before and after intervention, with a significance level of .05.
Borges Silva et al. 9
the participation of a person with blindness inthe process of the protocol development wasessential to define the “adaptive” therapeuticexercises to be chosen. This person identifiedsome terms that were not known to individualswith visual impairments. This information wascrucial in determining which terms, if theywere essential for an exercise, needed to beexplained, such as the term “analog clock.” Inaddition, working with an individual with vi-sual impairment helped us understand thatindividuals who were familiar with the termsin the protocol could participate better in theexercises.
The PP-PVI was developed in an exerciseblocks format. Each block contained physical,functional, and cognitive requirements thatwere carefully chosen to promote the gain ofphysical abilities and functional skills. Forexample, exercises 1 and 2 for mobility couldbe performed passively. However, since theparticipants required body awareness, theseexercises were performed actively. This typeof requirement ensures greater motor learning,particularly in the core muscles, which areessential for maintaining correct posture.These exercises also contribute to pelvic andshoulder girdles dissociation during gait.Exercises 3, 11, 12, and 13, which aimed toinduce gains in strength, did not use resis-tance weights (dumbbells), but instead werecalisthenic exercises. Thus, when using theresistance of body weight, the risk of injurieswas lower and the strength gain, althoughgradual, was progressive throughout theprotocol of the application period. Emphasiswas placed on exercises that promoted flexi-bility gains (exercises 4–9) exclude. There wasalso the option for active exercises to gainflexibility. These exercises had secondary ob-jectives: the stimulation of balance and coor-dination, which are especially importantaspects to individuals with visual impairments.Exercise 10 was for respiratory control asso-ciated with all the muscles involved in main-taining proper posture. This global stimulusallows significant gains in body awareness,which is typically compromised in people withvisual impairments. In addition, although it
may promote postural corrections, it improvesstability.
The range of motion limitation and balancefor each participant were considered during theimplementation of the PP-PVI, particularlywhen performing in the orthostatic exercises.Some participants needed external supportwhen they began these exercises, and eventu-ally they were able to complete them withoutsupport. According to these improvements,physical skills were required to perform theexercises without any support and with maxi-mum amplitudes.
The understanding of words by participantswas also a challenge for the final selection ofthe verbal commands for the protocol. Someterms like “clock” in exercise 1 and “riding” inexercise 12 needed to be clarified. Exercise 1was explained through the use of an ethylenevinyl acetate paper analog clock, and theconcept of pointers was explained with verbaldescription and tactile demonstration. Next, theclock was hung on the wall at hip level, and themovement of the pelvis was explained ac-cording to the position of the clock (12 h =retroversion, anteversion = 6 h, and 3 h and9 h = side slopes). As for the concept of “ridinga bicycle,” the participants had practical ex-perience on a stationary bike, and they wereable to repeat the movement in a lying position.
Despite the good level of understanding ofverbal commands, other adjustments werenecessary to the linguistic adaptation oncethe protocol was translated into English tofacilitate understanding. The review and anal-ysis of the translation by a native speaker ofEnglish with a background in linguistics werefundamental in this process. Exercises 1, 2,and 6 had their verbal commands modified.For example, for exercise 1 (pelvic clock),there was a breakdown of the clock positionsand their relationship to human anatomy. Thecommand “Imagine that your pelvis has thehands of a clock” was replaced by “Imaginethat there is a clock lying flat on your lowerabdomen, where your hands are. Twelve o’clockis at your belly button, and six o’clock is at thetop of your pubic bone. Your hip bones are atnine and three.”
10 Journal of Visual Impairment & Blindness 0(0)
The PP-PVI was performed by six partici-pants with visual impairments over an extendedperiod (12 months). During this time, motorlearning occurred gradually. In the first month,there was a greater emphasis on teaching thecorrect positioning of each exercise, and theverbal and tactile controls were fundamental tothe understanding of the exercises. Then, bylearning the sequence of movements of eachexercise, only tactile commands were used tocorrect positioning. This period lasted for ap-proximately one additional month. From thispoint, individual follow-up conducted by phys-ical therapists allowed each participant to evolvein their execution of the PP-PVI exercisesregarding load, number of sets, and repeti-tions according to their capabilities. The exer-cises were then carried out independently byparticipants, with only occasional verbal com-mand corrections during execution. Moreover,physical therapists began to use verbal com-mands to encourage individual progress in eachexercise. In the flexibility exercises, the largestrange of motion and the maintenance of stand-ing for a progressive time were stimulated. Inthe strength exercises, the increase in isom-etry time and the number of repetitions wereencouraged.
The analysis results regarding quality of lifeafter the application of the protocol, althoughnot significant, demonstrated improvement infunctional physical condition, overall health,vitality, social and emotional aspects, andmental health. These results corroborate thefindings of Marques et al. (2015), who alsoused an audio–tactile method for teachingaquatic therapeutic exercises to people withvisual impairments. However, a broader studyis needed to attest to the positive influence ofthe PP-PVI on improving the quality of life ofpeople with visual impairments.
The proposed protocol for people with vi-sual impairments was shown to be effectivedue to adherence, learning, and practice of theaudio–tactile exercises of the PP-PVI. Thus,the implementation of the PP-PVI could pro-mote changes to the sedentary behavior of theseindividuals. This change is extremely impor-tant because a sedentary lifestyle is associated
with higher mortality, hospitalization, cardio-vascular diseases, diabetes, and cancer, and isa risk factor for poor bone health (Chastin,Mandrichenko, Helbostadt, & Skelton, 2014),which can further aggravate the living andhealth conditions of a person with visualimpairments.
Therefore, breaking the vicious cycle ofinactivity becomes an important protectivefactor. In doing so, ensuring accessibility topractice physical exercises (via architecturaladaptations, facilitating communication, pro-fessional training, and development of specificprotocols, such as the PP-PVI developed inthis study) secures independence for peoplewith visual impairments to develop theirphysical and functional abilities, which pro-motes physical, social, and psychologicalgains, as observed in this study.
This study is part of a project in which theuniversity performs health promotion activitiesin the community, in partnership with the in-stitution specializing in visual impairment. Theproject is called “Comprehensive health carefor people with visual impairments” and hasbeen running without interruption since 2008,guaranteeing the continuity of actions.
Conclusion
The development of a specific audio–tactileprotocol for people with visual impairmentswas only possible through the combined effortsof many professionals and the active partici-pation of individuals with visual impairments.As a result of this work, the PP-PVI was shownto be an important method of therapeutic in-tervention, and one that is easy to understandand apply with people with visual impairments.The exercises of the PP-PVI facilitate the de-velopment of several physical and functionalcapabilities that are important to the indepen-dence of people with visual impairments. Thegain of independence was reflected in theperception of improvement of quality of life forthese individuals.
Additionally, the exercises included in thisprotocol were performed twice a week for anextensive period of time, which promoted
Borges Silva et al. 11
changes in to the sedentary lifestyles of par-ticipants. This change may help prevent manydiseases and ensure health. Besides havingbenefits, the application of PP-PVI represents aparadigm shift related to visual impairment.The first change is the modification of confi-dence of the person with visual impairment inrelation to their own ability to perform exer-cises. Lack of confidence in this area can resultin sedentary behavior and loss of health. Thesecond change is the way society views thepeople with visual impairments, since variousadjustments and changes can be included insocial environments so that they may be in-cluded. It is important to understand that spacecan be redesigned or adapted in a simple wayfor a person with visual impairment, enablingthe accomplishment of physical exercises orany other activity. Moreover, society’s way ofthinking should be reevaluated, seeking newways to live, treat and prevent illness, and seekhealthfulness. In doing so, the real inclusion ofindividuals with visual impairment occurs.
Acknowledgments
Acknowledgment to RubenAdery, fromLosAngeles,a pronunciation specialist and linguistic teacher fromthe Brazilian Sciences without Borders program.
Declaration of conflicting interests
The author(s) declared no potential conflicts of in-terest with respect to the research, authorship, and/orpublication of this article.
Funding
The author(s) received no financial support for theresearch, authorship, and/or publication of this article.
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