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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