University of Edinburgh
 

Let Me See!

The Importance of Positioning for Young People with Visual Impairment and Cerebral Palsy

Margaret Lee
Text version of commentary on video

Emma

Emma is 3 years old and has cerebral palsy. Her patterns of movement change from being very extended to being very flexed with her limbs curled in. She has some control of her head. She has no sitting balance and requires a lot of fixation at her pelvis and chest to allow functional movements of her arms.

Emma is longsighted but her glasses should help her to focus close up. Emma will not tolerate wearing them all the time but the number of occasions on which she wears them is gradually being increased.

Emma 1
1 Here we see Emma in a close one-to-one interaction session with her teacher. These sessions are an integral part of her individual education programme which is tailored to meet her physical, cognitive, visual and social needs.

2 She is sitting facing the teacher, (with her legs placed on either side of the teacher's hips). Her body is being supported and her arms are tucked in.

3 The sessions take place in the familiar nursery environment with minimal visual and auditory distraction.

4 The teacher is encouraging eye contact and visual attention using familiar songs and language, drawing Emma's attention by blowing on her face or moving in closer to her, simulating early mother/child 'conversations'.

Speech and Language Therapist: Suzanne Main

The main focus of Emma's educational programme is interaction; that is where she is going to learn her communication skills. It is a vehicle for her to learn about herself and the world around her. It is very important for Emma to work with someone who knows her well, who can engage her in very simple mother/baby-type games and who can keep her in a comfortable but stable position. That same person should also be able to wait and watch very closely for her to respond and can reinforce these responses giving them meaning and
significance, perhaps by imitating a noise she makes or by giving her a tickle when she makes a movement. That is the way Emma is going to learn what communication is.

Emma 2
5 Emma is sitting with her teacher behind her giving her the support she needs. She has a familiar toy in front of her.

6a Emma's hands and arms are brought forward to touch and explore the toy.
6b The toy, Mr Wobble, has various textures and different sound clues.
6c It is hoped this will reinforce what Emma is seeing and hearing, though at this early stage it is difficult for her to integrate the sensory information.

Emma 3
7a Emma enjoys lying on the wedge. Her hips and knees are bent over a large sandbag which breaks up the total pattern and allows her to bring her arms and hands into the middle. This position is good for encouraging Emma to look. It also provides an opportunity for staff to observe how she is using her vision. Brightly coloured contrasting streamers in a soft material are used. The environment is controlled to reduce glare. Other visual and sound distractions are removed. The natural movement of the streamers helps attract and hold her attention. This provides Emma with visual stimulation similar to that experienced
by a baby in a cot or pram.

Emma 4
8a Now Emma is in a prone position over a small roll. This allows her arms and hands to remain forward and in midline and encourages the development of her head control.
8b At this time this is the only position in which she has voluntary control of her arm and hand movements and it lets her explore toys and objects both through seeing and touching. Only minimal support from an adult is required to maintain this position.

Physiotherapist: Christine Shaw

This is an ideal position for Emma and it is one that she enjoys. The flexed pattern of her lower body over the small roll fixes her hips and pelvis and allows her to stretch her arms forward to play with the toy or to use what vision she has. Emma also experiences quite
painful flexor spasms and this position alleviates these for her.

Emma 5
9a Here we see a play session with the nursery nurse. Emma's equipment includes a supportive chair to give the maximum fixation she requires. She is wearing a 'waistcoat' which attaches to the chair and gives her additional support.
9b An eye-catching black and white toy is used. Her tray has been given a matt black surface to avoid glare, and its border is outlined in pink for contrast.

Emma 6
10a A visual stimulation video is being used here which has striking sound effects to attract attention to the bright and changing patterns.
10b The TV monitor is placed on an adjustable table whose height has been matched to that of Emma's chair. Her tray has been removed to allow her to get near the screen.
10c She is wearing her glasses. They are to correct long sight and may help her focus on the patterns. Emma will not tolerate wearing them all the time but the number of occasions on which she wears them is gradually being increased.
10d The video was first used with Emma in the dark room to provide optimum contrast. Her visual attention has improved and she now looks at the patterns in the normal lighting environment of the nursery.

Teacher: Helen Gair

Visual stimulation videos are initially used in the dark room with the children until they become accustomed to them. We would then hope to use them in a more normal lighting environment as we would with any other visual stimulation material. Emma particularly enjoys being in the dark room. She likes lying on the bean bag beside the mini bubble tube which as well as visual stimulus gives her vibration.

Scott

Scott is 6 years old and has cerebral palsy and a left hemiparesis or weak left side. All Scott's movements tend to be effortful and jerky. Since infancy his vision has given cause
for concern. Scott's new glasses to correct long sight and astigmatism should give him a
clearer 'picture' of the world.

Scott's eyes frequently roll upwards. This seems to be connected with his head movements. He is unlikely to be able to use his vision when this happens. It is important to encourage Scott to use his vision at all times and correct positioning can help ensure this.

Scott 1
1a Scott is having his lunch in his supportive chair. He needs help to eat his lunch and here the occupational therapist is working with him. She is helping him to control his head and hand movements.
1b Meal times are a natural time to encourage and work on self help skills. Scott is able to eat his snack independently, and join in conversations with his teacher.

Occupational Therapist: Fiona Brownlee

There are four ways we are working on Scott's independence programme. One is by giving him auditory cues and getting his attention focussed on his plate by perhaps tapping it or asking him "What's for lunch today?". Secondly, we are working on his physical limitations by holding his head in midline and helping him to get his hand to his mouth. Thirdly, we
are providing him with specialised utensils and equipment, for instance, non-slip mats, built-up handles to his spoon, arm gaiters and hand splints which all help his independence. Fourthly, we are really just making it fun and enjoyable.

Scott 2
2a Scott is sitting at the touch screen astride his teacher's knee. The position of his legs inhibits his flexion pattern thus allowing him to straighten his arms to reach out for the screen. It is important to keep his feet off the floor to prevent total extension which would throw back his head and his eyes would roll upwards.
2b It is a good position for facilitating hand-eye coordination. He is wearing soft splints to encourage a less clenched hand position. It also gives the security of being close to a familiar adult. Scott was initially wary of the computer programmes. His glasses correct his longsight and astigmatism. He has to be encouraged to use his central vision.

Scott 3
3a At story time the teacher sits to Scott's right where she can bring the book close to his best side for vision.
3b A circle of friends is ideal for individual and group participation.
3c This is a favourite story for Scott. His excitement tends to increase the level of his tone. Effort on Scott's part also increases his tone so this must be borne in mind when planning an activity needing concentration and use of vision.

Scott 4
4a If independent mobility is possible it provides an invaluable experience for the child. Scott uses his vision to determine his route while moving independently, aided by his walker, instead of being pushed in his wheelchair.

Physiotherapist: Christine Shaw

Scott's walker was purchased for him by his mother who was very anxious to see him upright and able to move around his own environment. Scott loves being in his walker and being able to move himself around the room. Also, Scott's hips are at risk of dislocating and being upright and mobile-weight-bearing is one of the ways that we counteract this. I know that Scott does not use a good pattern in order to move himself in his walker but I feel that this is outweighed by the benefits he gains from being able to explore the room and his environment for himself.

Anita

Anita is 10 years old. She has cerebral palsy affecting her whole body and without proper support she tends to turn to the right. She has few voluntary movements, no sitting balance and is unable to participate in any gross movements. Anita has little or no vision in the right eye. The left eye fixates and follows well, slower when following to the left. She is unable to
look up and so is restricted to the lower field of vision. This means that she will not see the top half of adults walking around.

Toys and objects can be presented at the normal viewing distance if they are well contrasted and attention is drawn to them. Although Anita has a potential for seeing, it can be limited
by what she understands and this can affect what use she can make of what she sees.

Anita 1
1a Anita and her classmates begin their day with a 'hello' song. Anita is sitting on a stool, feet flat on floor, supported by the physio behind her. Her teacher is positioned down to Anita's left to discourage her natural pull to the right and also to help her use her lower field of vision.
1b Time is given for Anita to take in what is going on and respond appropriately.

Anita 2
2 Experience of vestibular stimulation, visual flow and swift movement is given through rocking in a blanket. This movement through space, and the class rough and tumble play sessions, provide Anita with experiences which she otherwise would not get because of her physical disabilities and inability to move her body.

Anita 3
3a Moving through space can also be used to build up appreciation of distance - moving towards and away from people, in this case the teacher, or the floor.
3b A variety of physical sensations are being brought into play, eg; bouncing and encouraging her arms to stretch forward. Lying on the ball helps to mobilise her spine and her limbs.
3c When she is lying on her back on the ball yet another exciting experience of seeing the world upside down is open to her - she can now see some of what we see in our upper field of vision.

Anita 4
4a The multi-sensory Snoezelen room provides the ideal setting for an intimate session with her teacher. The calm atmosphere, subdued lighting and relaxing music help Anita enjoy some hard work tracking an object.
4b Anita has little or no vision in her right eye. However, her left eye can fix on and track an object. The sound of the ball rattling in the whisk attracts her attention.
4c This is also a good physical position for Anita as she has some support and she is lying straight. Her windsweep to the right is being discouraged as her teacher is working on her left side.

Anita 5
5a In this group session led by the speech and language therapist, Anita is sitting on a stool, her feet on a block and supported by a classroom assistant.
5b Ideally, Anita should be in her support chair as are the other children. However, she often refuses to go into her chair and today was one of those days.
5c Although Anita can vocalise she also uses a modular arm switch controlled by her head to let her experience voice output communication for play and in the future it may be a method for controlling her environment.
5d Anita's physical positioning is affected when she is excited or making an effort and the classroom assistant can be seen supporting Anita's pelvis.
5e Throughout the lesson the speech and language therapist always bears in mind the best viewing position for Anita using familiar, distinctive play materials, held against the contrast of dark clothing.

Speech and Language Therapist: Suzanne Main

This was a very familiar, favourite play session used to encourage Anita's pre-linguistic skills and her communication. Anita is expected to listen, to recognise and to anticipate during the game and she is also using her voice to actively participate to call my attention to indicate "Yes" to me. She is also using a very simple voice-output communication aid to join in the game.

James

James is 13 years old and has cerebral palsy with spasticity affecting mainly his lower limbs. His tone is high throughout all four limbs but his left side is less affected than his right. James can be placed into an independent sitting position, but he needs support to balance.

James' right eye turns out (divergent) and he mainly uses his left eye to see. He needs to bring pictures or symbols close in order to see detail. Use of sound and touch helps James to supplement the limited information gained through sight. He is also very good at asking questions! Like many young people with visual impairment James uses language to help him control situations in which he finds himself.

James 1
1a James is seen playing dominoes with two friends, his teacher and a classroom assistant.
1b His visual attention is directed by the teacher to the dominoes which are colour-coded allowing James to use the colour to choose appropriately. He also supplements his vision through touching the tactile shapes on the dominoes.

1Reference: Mayer-Johnson Co (1994) Boardmaker 3.0 for Macintosh:
User Guide and Manual: Mayer-Johnson, USA
These Mayer-Johnson picture communication symbols are used worldwide but were originally developed by staff at Erinoak, a multidisciplinary facility for physically disabled up to the age of 21, located in Canada.

James 2
2a Computer work, in this instance, using the touch screen, is a part of James' programme. He needs to be very close to the screen to see. However this means he is sometimes distracted by the equipment itself. This can interfere with the learning process and must be taken into account when introducing James to any new piece of equipment and time must be allowed for this tactile exploration.

James 3
3a James is encouraged to use his vision to identify pictures and symbols which will help him in later life in identifying social signs and notices. He uses a switch-controlled 'choice-maker' to help him to concentrate on the task in hand and 'focus' on the activity.

Occupational Therapist: Fiona Brownlee

Whilst acknowledging that James does not need to select drinks through picture symbol recognition, one of his aims is to build up on his social symbol recognition so that when he goes out into the adult world, he can recognise signs like 'toilet', 'fire exit', etc and this is in
keeping with the group's aims.

James 4
4a The power chair gives James more independence than his self-propelled wheelchair. He uses sound cues, such as the assistant's voice, to help him navigate.
4b James makes good use of his limited vision for navigating his chair. He orients himself using the yellow and red house as a visual landmark. His more able left hand uses the control switch and he safely navigates the chair into the classroom.

Conclusions

This video has illustrated the ways in which teachers and therapists have to plan to ensure that their pupils' visual and physical needs are taken into account. For a particular activity the visual needs may predominate and a less ideal physical position may be adopted. What is important is that the person in charge of a particular part of the curriculum is clear about its aims and ensures that the pupil is positioned in the most appropriate way, having taken into account the activity in question and the visual and physical needs of the child.

With thanks to staff and children at
Westerlea School, Edinburgh