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5 Innovative Vision Rehabilitation Concept: Theoretical Postulates, Meanings and Objectives

5 Innovative Vision Rehabilitation Concept: Theoretical Postulates, Meanings and Objectives

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Innovative Vision Rehabilitation Concept: Theoretical…


Vision rehabilitation contributes to the prevention of the risk of deprivation of the

cognitive and emotional development of personality, to minimization of deterioration

in quality of life depending on visual disorder and to an increase in performance and

possibilities of involvement.21 It can be understood as a comprehensive concept of

educational and training rehabilitation procedures based on the activation of personal potential (Lopuchová, 2010). The procedures use stimulus response situations

with a strong emphasis on factors that determine visual comfort, effective use of

assistive devices and technology and synergy of all sensorimotor and mental functions.

The dominant emphasis is on the involvement of cognitive abilities, experience and

personal qualities of the individual, which brings on board also the education

moment.22 In adulthood, vision rehabilitation processes can influence:

– Skill of effective use of partial sight

– Skill of providing visual comfort in various types of activities

– Knowledge and a wide use of supportive techniques (visual hygiene, relaxation

exercises, diet and regimen) (Anton, 2007)

The importance of further targeted education is evident: achieving sufficient

knowledge of one’s own possibilities and limitations in the use of partial sight;

developing effective use of internal as well as external variables; targeted improvement

in performance in specific required activities; prevention of further deterioration of

vision due to the negative effects of the environment (Krüger, 2004; Kunnig, 2004;

Lueck, 2004).

This concept of vision rehabilitation finds its use in all ages. In early childhood,

mainly functional assessment and visual stimulation are applied. In preschool age,

the most important area is the development of all senses and their functional synergy through the involvement of the whole personality. In school age, the primary

concern is to ensure effective methods of education in various types of schools and

effective use of visual abilities to reach optimal level of self-sufficiency and independence. In the target group of adults and elderly adults, vision rehabilitation is

applied as a means of preserving quality of life (Jesenský, 2007; Keblová, 1996;

Květoňová-Švecová, 1999; Vítková et al. 1999).

The rehabilitation objectives should be achieved through a coordinated system of

services, which include:

– Assessment of functional ability and visual performance

– Environmental adaptations and modifications

– Consultancy and support of effective and healthy use of partial sight in activities

of daily living

– Training in improving the effectiveness of the use of assistive and rehabilitation aids

– Use of visual skills in movement


Even more important is the position of visual stimulation and development of functional visual

performance in persons with dual sensory impairment (Ludíková, 2005).


Education and learning to the optimal use of visual capacity, effective use of vision in specific

situations and activities, means of visual hygiene, preventing the risk of further deterioration or the

maximum deceleration of the process of progressive disease.



Concept of Vision Rehabilitation in the Czech Republic

– Support of complete physical, mental and social well-being (including educational

and rehabilitation impact on family members)

– Other additional resources

The objectives of vision rehabilitation can be understood in two basic aspects:

the improvement of visual performance and the fulfilment of individual’s needs.

Objectives in terms of professional approach

Rehabilitation professional must be able to differentiate between visual disorder,

disability and their implications in activities of daily living and social life. He/she

should be able to assess which educational, rehabilitation and social services can lead

to an improvement in individual’s specific situation (Silvestrone et al., 2000).

Objectives in terms of the needs of the individual

Care and services must bring a positive result which is subjectively perceived as

acceptable from the perspective of the person and his/her family (Lueck, 2004).

Massof (2003, in Lueck, 2004) classified the objectives of comprehensive vision

rehabilitation into three categories: achieving a partial or complete correction of the

function through treatment and optometric interventions, achieving an improved functional use of partial sight based on the mastery of rehabilitation (or assistive) strategies

and providing the full range of educational and rehabilitation support and services.


Target Groups

Vision rehabilitation is an adequate solution for persons with such a degree and type

of visual damage which causes disadvantage in activities of daily living. There is

also an assumption that special education, training and environmental adaptation

can contribute to the improvement of visual performance. In terms of development,

it is possible to list the following target groups:

– Persons with congenital visual disorder—education and training as the saturation of

need for the solution of newly created critical situations

– Persons with acquired visual disorder (including the specifics of old age)

– Persons with progressive disease and permanently deteriorating quality of vision

The characteristics of the target group in terms of the degree of limitation of

visual function are described in more detail in another part of the book. Experience

has shown that the degree of the restriction of visual function may not always be

dominant factor in the degree of functional use of visual potential in common tasks

and in the potential of further improvement in performance or in the subjectively

experienced quality of life (Galvas, 1999; Silvestrone et al., 2000, Žiaková &

Hricová, 2007). According to Bäckman’s and Inde’s research (1979), with regard to

the needs of education, it is optimal to classify the target groups of vision rehabilitation on the basis of type of functional difficulties23:


One person can be functionally classified into several of the listed groups.


Innovative Vision Rehabilitation Concept…


Group with limited or full loss of central visual field

Group with limited or full loss of peripheral visual field

Group with involuntary eye movements

Group with other forms of amblyopia

Hyvärinen (2001a, 2001b, 2001c) adds to this list the group of persons with central visual impairment (CVI).

Another classification of target groups in vision rehabilitation is given in Beliveau

and Smith (1980). Persons with disorders are put into groups according to their ability to use optical devices (one person may qualify for more than one group):

– Persons for whom the optical devices and strategies of their use constitute an

important potential for the development of performance

– Persons who cannot achieve any improvement of visual performance via optical

devices, therefore their vision rehabilitation takes place mainly without such


In terms of specific approaches, age is an essential criterion. The classification is

specified in the previous chapters: early, preschool, school age, adulthood and late



Comprehensive Concept

In connection with the trends of the development of society, changes in the quality,

quantity and structure of social and rehabilitation needs have occurred. Much of

professional interest has been focused on the creation of modern concepts and the

elaboration of the theory and research of comprehensive rehabilitation field, which

relates to need for introducing new legislation. A significant quantitative and qualitative development of non-governmental organizations responds to the needs of

practice to complement state-guaranteed care and services. Rehabilitation (as well

as the entire field of education) is expanding its range of activities for lifelong perspective (especially educational and vocational rehabilitation and supportive interventions for the elderly). The current situation strongly supports the

professionalization of rehabilitation services (Valenta, 2001). Other significant

areas of development are assistive devices and technology as well as enlarging the

spectrum of rehabilitation services towards the target groups of persons with severe

and multiple disabilities.24

The need for a further development of rehabilitation can be viewed from several

perspectives. The first is associated with the global concept of rehabilitation in the

spirit of multifaceted perception: respecting the individuality of person as a partner,


An example is the legislative separation of services for persons with deafblindness as a separate

target group in the Czech Republic, but also the change of approach to persons with severe intellectual and multiple disabilities.



Concept of Vision Rehabilitation in the Czech Republic

which moves from the dominance of disability itself to the dominance of respect to

special needs in various life dimensions of the person (using potential abilities,

respecting the needs and interests of the person). The second aspect is the promotion

of inclusion. The third area of development is the synchronization and the completion of comprehensive rehabilitation concept from the existing systems, meeting the

special needs of various target groups including the increased integration of psychological support to the system of adult and older adults rehabilitation. The fulfilment of these priorities would create a wide platform for a further development of

interdisciplinary field, the main objective of which is to achieve an acceptable quality of life (Jesenský, 2000).

The comprehensive concept of vision rehabilitation has the character of lifelong

guidance in both its basic types: rehabilitation of persons with congenital and acquired

disorders. It is developed into four primary components. Their cohesion and coordination in application will lead to a complex solution for the individual’s life situation.

The basic components of rehabilitation were listed by Pfeiffer and Jesenský (1995):

therapeutic, occupational, social, educational.25 Although all the components seem

well thought over, the process remains significantly variable26 (Jesenský, 2000).

Creating a concept of comprehensive rehabilitation for the target group of persons with low vision is mainly determined by: development of methodological field;

ensuring the continuity of individual components of rehabilitation and ensuring a

wide availability of services throughout the country. To accomplish this, the following steps must be implemented:

1. Founding a centre for rehabilitation of persons with visual impairment. For this

purpose, it would be possible to adapt ‘Centre of Visual Impairment’ into the

main methodological centre.

2. Extension of the medical component of rehabilitation (vision therapy) also at the

level of each region as an integral part of treatment at ophthalmologic clinics or

in specialized ophthalmology surgeries so as to ensure the cooperation of vision

therapists in the comprehensive diagnosis of visual ability and functional performance and the assessment of rehabilitation needs. At the same time, vision therapist would be also responsible for ensuring a continuity of further rehabilitation

care and services.

3. Standardizing the continuity of services and the interdisciplinary cooperation of

medical professionals with other components of rehabilitation; participating in

the creation of rehabilitation plans (Šťastný, 2006).

4. Defining competences between the medical and social components of rehabilitation

(vision therapy and vision rehabilitation). Ensuring the continuity of vision rehabilitation, directly after medical interventions; and developing visual performance


Some other components, which Jesenský (2000) defined as complementary, currently correspond to the basic needs of adult vision rehabilitation. This is particularly the component of psychological and technical rehabilitation.


Due to the absence of new legislation on rehabilitation, systematization is delayed. Many experts

consider the absence of integration of vision rehabilitation into the health care system as the determinant of further development (Pfeiffer, 2005; Šťastný 2006; Švestková, 2005).


Innovative Vision Rehabilitation Concept…


through the outpatient forms of vision rehabilitation (support of environmental

adaptation and training in the real environment, etc.).

5. Developing other rehabilitation programmes specifically aimed at the needs of

persons with low vision.

Compared to foreign professional systems,27 the rehabilitation of persons with

low vision has been yet considered only a complementary discipline in the Czech

Republic. The above given analysis and the draft proposal of changes seek to change

the view. The development aims to change the quality of services for the vast majority of persons with visual impairment.

The current state of the implementation of vision rehabilitation in Czech practice can be best explained by the description of existing activities. In terms of the

focus of this work, this description will be limited to the target group of adults and

older adults.

The theoretical discipline of vision rehabilitation is part of the special education

of persons with low vision (Jesenský, 2000). However, due to various factors

(brought about by social changes after the fall of communism in 1989), it started to

develop as a rehabilitation discipline. The key factors were: decentralization of special education (abolition of the specialization of schools—for children with low

vision, with near-total visual impairment and with total visual impairment); massive

onset of integrated education; emergence of many non-governmental organizations

for various age groups which gradually assembled under the rehabilitation umbrella;

and, last but not least, efforts of theoretical elaboration, systemization and application of the knowledge for the target group of adults (in 1970s and 1980s), which

took place in connection with the development of comprehensive rehabilitation.

With the recognition of rehabilitation as a complex, internally structured field, it

became possible to consider visual training a key discipline of the comprehensive

vision rehabilitation (Fig. 3.3).

Even though vision rehabilitation is applied in practice, it is very important to

develop it also theoretically as an educational discipline to maintain its distinctive

educational nature (Jesenský, 2002).


Basic Factors

According to Jesenský (2007), there are five basic factors involved in the process

of rehabilitation, influencing its course and outcome. First of all, it is the potential

of the individual himself/herself (anatomical, neurophysiological and psychological

characteristics including the level of low vision). The process of rehabilitation also

affects lifestyle and other biological and psychophysical conditions which enable or

obstruct the achievement of a balance of organism and environment. An important


Bäckman (1998); Dickinson (2002); Lueck (2004); etc. An example of interdisciplinary approach

in the USA is given in Table 3.1.



Concept of Vision Rehabilitation in the Czech Republic

A draft proposal of rehabilitation system for persons with low vision in the CR

Science and research

Assistive devices and technology

SONS / national

Social rehabilitation

Medical care

Specialized ophthalmologist

Methodological centre of


Health facilities / regional

Centre of visual

impairment /


Vision rehabilitation


Orientation programme

Reading skills programme

and other rehabilitation


Tyfloservis o.p.s. /


Medical rehabilitation

Optometrist; Optician

Vision therapist


Vocational rehabilitation

Vocational training programme

Retraining programmes

Tyflocentrumo.p.s. / regional

Medical facilities /


Dědina Residential Rehab. And

Requalification Centre/ national

Fig. 3.3 A draft proposal of rehabilitation system for persons with low vision in the CR

role is played by technical aids, environmental adaptation and modification, methods,

techniques, procedures and forms of purposeful action. The last factor consists of

human potential (experts and other participating workers).

Some of these factors are more general, and as such were described in other

authors chapters. Subsequent chapters will deal more with the factors which occupy

specific position in the process of vision rehabilitation.

Psychosomatic Conditions

The educational and rehabilitation concept of vision rehabilitation can be seen as a

dynamic phenomenon with targeted behaviour. A number of variables enter the

process and positively or negatively influence the resulting effect. Barraga (1976)

sets out the following principles of educational approach in vision rehabilitation:

– Visual functions do not develop automatically.

– Level of visual perception is not a fixed variable (it cannot be judged only on the

basis of clinical diagnostic tests).


Innovative Vision Rehabilitation Concept: Theoretical Postulates, Meanings…


Exogenous and endogenous effects of CVR

modification of visual conditions

multifactorial approach

visual images and sensations

mental and physical conditions


individual approach

multisensory approach


visual training




optical devices


supportive interventions


Functional increase in visual performance

Fig. 3.4 Functional increase in visual performance I. (CVR—comprehensive concept of vision

rehabilitation) (Růžičková, 2002)

– Visual performance is not necessarily affected by the type and degree of decrease

in visual ability.

– Most abilities of the use of partial sight can be positively influenced by educational

means for creating visual experience and increase in performance.

As a starting point for the analysis of educational potential of variables, it is

necessary to take into account the fact that the specific problems of persons with low

vision in adulthood have a different character compared to other age groups. Most

persons with later acquired visual performance limitations tend to use even the

slightest visual capacity. However, an activation of adaptation abilities does not

occur automatically. Rehabilitation procedures are therefore an important need and

potential for the development of visual performance of most persons with low vision

(Jesenský, 1994; Růžičková, 2006).

The following text will focus on a closer specification of input variables by

specifying the characteristic problems which emerge in relation to the reduction of

the amount or intensity of visual stimuli in the reference spectrum of target group

of adults as well as the problems which most frequently affect the conditions of

education (Fig. 3.4)28:

– Absence of the knowledge of rehabilitation techniques and procedures (without

professional support, it is virtually impossible to adapt to new situation).


General characteristics and specifics of the needs of target group of persons with low vision are

listed in Sect. 1.2.7.



Concept of Vision Rehabilitation in the Czech Republic

– Lack of ability to use effectively an increased level of the synergy of information

gained through other senses and cognitive strategies.

– Increasing fatigue of nervous system in relation to the need for an increased level

of focused attention in activities of daily living.

– The need to deal with an increased number of visual errors and their


– Disproportion between visual abilities and performance requirements.29

– Problems in education and rehabilitation are also caused by individual differences

in the quality and quantity of functional visual capacity (or variability) and individual

ability to use it in various activities and situations.

– Difficulty with the adaptation of external conditions for an effective use of partial


– Adaptation to complications caused by the combination of visual disorder with

other functional disorders or diseases.30

The main areas, in which an increase in visual performance can be anticipated

thanks to vision rehabilitation, are demonstrated in Fig. 3.5.

The importance of vision rehabilitation does not only consist in the increase

of visual performance in activities of daily living. It should also result in an

increase in the overall quality of life and the overall ‘health’ of the person as

defined by the WHO: physical, mental and social well-being. Thus, vision rehabilitation affects:

– Psychological experience (by changing attitude towards one’s own vision, gaining

confidence and effectiveness of visual behaviour and performance, mastering the

techniques of mental hygiene, etc.)

– Physical health (by supporting healthy lifestyle, limitation of the harmful effects

of environment and supporting the strengthening effect of supportive dietary,

exercise and regime elements in terms of the prevention or elimination of further

progression of the disease and a positive reflection on the overall condition of the


– Social networking (using the results of two previous components to increase

participation in communication, information management, autonomy and other


During adulthood, social environment has high expectations as to the performance of the person,

which generates mental frustration. An example is mobility. In case of persons with total visual

impairment, a lower level of mobility is tolerated by general public. However, persons with low

vision are expected to be self-sufficient. Mastering mobility in various conditions can be mentally

challenging (e.g. mist, twilight, glare).


Most frequently occurring complications in adulthood and old age are: diabetes mellitus, other

internal diseases, hearing impairment, physical disability, damage to CNS with a variety of consequences, etc. Only in case of dual sensory impairment, the unique situation is respected and education and rehabilitation is organized through the network of specialized organizations. Other

combinations are incorporated into categories based on the dominance of one of the disorders or




Innovative Vision Rehabilitation Concept…

Functional increase in visual performance

improving orientation

improving resolution


using special techniques

improving coordination

mastering object environment

acceleration of performed


facilitation – improvement – acceleration

psychological effect

comprehensive rehabilitation

Fig. 3.5 Functional increase in visual performance II (Růžičková, 2002). CVR—comprehensive

concept of vision rehabilitation

areas which strengthen the competences of the person in community) (Silvestrone

et al., 2000)

Understanding initial conditions, variables and possibilities of their effective

interaction is a very important prerequisite for the preparation and implementation of

functional assessment, individual rehabilitation plan and actual process of rehabilitation. Their assessment leads to an exact specification of visual ability in relation to

the overall performance of the person (skill to use partial sight, capacity of further

development through education and expected level of impact of vision rehabilitation

on quality of life).

Specific Approaches and Principles

The comprehensive concept of vision rehabilitation respects all the general

approaches important for the fact that the subject of interest has a certain age and is

in a stressful situation (from biological, therapeutic, psychological, educational

point of view) (Lopúchová, 2006). The specific approaches primarily include:

The Interdisciplinary Team Approach

One of the conditions of comprehensive approach to the problem is to link existing services into a single cooperating and coordinated system. The principle

members of interdisciplinary team should include: general practitioner, medical



Concept of Vision Rehabilitation in the Czech Republic

specialists, special education teacher—rehabilitation professional, vision therapist, social worker, eventually other specialists. The modern trend of comprehensive vision rehabilitation should make the optimal use of technically demanding

rehabilitation and assistive devices and systems. This trend of development will

cause an expansion of the team by other experts from various technical sectors.

Also a family member should become a full member of the interdisciplinary team

as only family has a direct experience with real problems, needs, motives, goals

and lifestyle of the individual (Wilkinson, Stewart, & Trantham, 2000; Lueck,

2004, etc.).

The model prevalently used in practice is the model of team cooperation based

on effective partnership. From this perspective, Lueck (2004) highlights several key

factors which constitute an optimally functioning interdisciplinary team:

1. Creating an interdisciplinary team—selecting team members on the basis of the

need assessment of the individual.

2. Organizational structure—the form of team composition is variable (either a

single interdisciplinary team for all people or a unique team of professionals for

each person).

3. Clinical or applied approach—in case of clinical approach, individual interventions are performed in specialized offices and laboratories through specialists.

The applied approach tends to simplify the whole process. Some interventions

take place in the person’s home.

4. A large number of team members reduce the quality of effect as it complicates

effective communication and cooperation. From this perspective, a smaller,

intensively cooperating team of professionals is better suited for the task.

5. Coordination of the roles of team members—the level of participation of each

member differs. The effectiveness of cooperation depends on the way the roles

are organized. All the team members should participate in the initial interview

and evaluation meetings. Each team member should conduct the interview in

his/her area of expertise as well as learn about all other areas of the person’s

needs. Another possibility is the individually conducted interview in each area

of services.31

The Multifactor Approach

Rehabilitation process must be understood as a target-driven dynamic process.

The implication is that it is influenced by a number of exogenous and endogenous

variables (more or less, positively or negatively). Practical experience shows that

partial improvements of the individual in multiple areas of educational intervention contribute more to the overall improvement in visual performance than a


An important role in the modern concept of rehabilitation services is played by ‘the advocate’.

His/her task is to defend the interests of the individual to oversee the optimal implementation of

rehabilitation plan and to evaluate the achieved results (Lueck, 2004; Lund & Dietrichson, 2000).


Innovative Vision Rehabilitation Concept…


significant shift in just one area. The primary requirement is to put educational

and rehabilitation process into the context of existing relationships (conditions,

opportunities and needs).

The Multisensory Approach

If the multisensory approach is generally considered one of the essential means of

perception and learning, it is even more important for the area of special education of

persons with visual impairment. The principle of strengthening the partial flow of

information requires an increased use of compensation functions. The most commonly used are touch, hearing, smell, movement, taste, thinking and speech

(Jesenský, 1995). The combination of the use of vision and the compensation ability

of other senses must be responsibly chosen depending on the abilities of the individual and type of performed activity. The following list provides the most frequently

applied combinations:

– It is important to support the habit of an effective use of partial sight in situations

and activities where it is appropriate (eventually to supplement it by using

compensation functions for additional information)32.

– It is appropriate to consider the use of compensation functions in situations and

activities in which the choice of assistive technology can result in a higher final


– It is advantageous sometimes to completely exclude the use of partial sight and

give preference, instead of vision, only to compensation functions—for instance,

in situations or activities in which the real level of partial vision would bring

minimal effect or it would be gained at the expense of an excessive degree of

invested effort.34

The aim of this approach is to offer a coordinated educational effect in such a way

so that the person could effectively master the use of vision and combine visual perception with the use of compensation functions and assistive means. The final result

is a synthesis of sensations coming from multiple senses as supplementary information channels. The purpose is judicious distribution of methods and techniques in the

daily regimen of the person to avoid prolonged overloading and eyestrain so that the

resulting performance corresponds to the effort and time spent. It is important to

achieve visual comfort whilst using partial vision.


For instance, the use of computers with screen magnifying software and additional use of voice



For instance, whilst working on computer, to use voice output as the major means of communication (especially for reading documents); functional vision only for orientation on screen.


For instance, giving preference to listening to audio books rather than to using optical devices.

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