UPDATES IN SPECIALTY CARE Focus on Capabilities Not Disabilities– Sports and Recreation for the Visually Impaired Service Member and Veteran

Bobbi L. Hillen, LCSW; Felix M. Barker II, OD, MS; Imelda V. Llanos, MS, OTR/L; Mary G. Lawrence, MD, MPH; Donald A. Gagliano, MD, MHA; and the Vision Center of Excellence Technologies Assessment Working Group*

Because most activities of daily living are visually guided, effective visual rehabilitation strategies require the use of a variety of adaptive techniques and technologies that take full advantage of the individual’s capabilities. This is especially true of service members and veterans who, because of their injuries, would like to continue to participate in sports, recreational and athletic activities, and competitions.

ervice members of the U.S. (DoD) and the Department of Vet- deliver a sufficiently coordinated and Armed Forces and veterans erans Affairs (VA) serve the visually robust set of services. This has led to are affected by many visu- impaired, although since WWII, it the establishment by Congress of the Sally disabling conditions, in- has been the primary responsibility DoD/VA Vision Center of Excellence cluding combat eye injury, traumatic of the VA’s Blind Rehabilitation Ser- (VCE) (See “DoD/VA VCE”), to bet- brain injury (TBI)-related visual dys- vice to provide most of the rehabili- ter enable effective visual rehabilita- function, and age-related eye diseases. tation services to active duty service tion of all of our wounded service Patients with significant losses of members and veterans who are visu- members and heroes with disabilities. central vision, peripheral vision, or ally impaired. The current conflicts total blindness require rehabilitation in Iraq and Afghanistan, coupled with SPORTS AND RECREATION to successfully function in their daily the aging veteran population, have Participation in sports and recreation activities. Because most mobility and placed an increasing demand on both events and activities are important to other activities of daily living (ADL) of these federal health care systems to the health and fitness of all persons. are visually guided, effective visual rehabilitation strategies require the The VHA ’ s Specialty Care Services includes medical use of a variety of adaptive techniques services with a wide range of subspecialties; emer- and technologies that take full advan- gent and urgent care and patient support services, tage of the individual’s capabilities. such as nutrition; spiritual care and other specific- Both the Department of Defense purpose programs, such as cancer registry and Centers of Excellence for multiple sclerosis, epilepsy, Ms. Hillen is associate director of rehabilitation, and Parkinson disease. The Office of Specialty Care Dr. Barker is associate director of rehabilitation Services brings you “Updates in Specialty Care,” shar- research, Dr. Lawrence is deputy director, Dr. Gagliano is executive director, all at the DoD/VA ing the latest evidence-based approaches, each column featuring a differ- Vision Center of Excellence in Bethesda, Maryland. ent topic and providing updates on existing programs, and introducing Ms. Llanos is program manager at the Physical new programs. Special thanks to Margaret (Maggi) Cary, MD, MBA, Medicine and Rehabilitation Vision Impairment Clinic at James A. Haley Veterans’ Hospital in Tampa, MPH, director of the VA ’ s Physician Leadership Development Program, Florida. Dr. Barker is also an emeritus professor at who coordinates and edits the column. Please send suggestions for future Salus University in Elkins Park, Pennsylvania. columns to [email protected]. *Please see end of article for a complete list.

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yet classified as Paralympics sports, DoD/VA VCE such as archery, baseball, bowling, The VCE is 1 of 4 congressionally-mandated Centers of Excel- golf, sailing, shooting, and water ski- lence within the DoD that is charged with improving the quality ing. As the “Para” in “Paralympics” implies, sports participation for per- of care and recovery of our wounded warriors. The VCE was sons with a disability traditionally had created by Congress (National Defense Authorization Act, a much larger footprint for persons 2008) to: with paralysis and amputation inju- • Collaborate to the maximum extent practical with the VA ries. In contrast, sports for persons institutions of higher learning and public and private entities with visual disabilities are a more re- on both the national and international level cent addition to the competition, pos- sibly accounting for only about half • Address issues related to the prevention, diagnosis, mitiga- the number of para-events compared tion, treatment, and rehabilitation of military personnel and with those for disabled persons with veterans affected by eye trauma and assist those suffering normal sight.6,7 However, there is a from vision impairment associated with a TBI and posttrau- second reason that athletics for the matic visual syndrome visually impaired lags behind other • Develop a defense and veterans eye injury and vision registry para-sports. Compared with other physical disabilities, visual disabili- The VCE mission has been established as follows: “To con- ties are unique in their impact on the tinuously improve the health and quality of life for members of athlete, because they impair visually the armed forces and veterans through advocacy and leader- guided bodily movement, causing a ship in the development of initiatives focused on the preven- physical limitation even when there is tion, diagnosis, mitigation, treatment, and rehabilitation of no physical impairment.8,9 Because of dis­orders of the visual system.” this, “blind” sports have a significant need for alternative rules, adaptive technology, and the engagement of However, service members and vet- COMPETITIVE SPORTS trainers, mentors, and sighted guides. erans with disabilities have an even The benefits of athletics are especially One important issue in competi- greater need to participate in order to important for service members and tive sports for a person with vision maximize their physical health and veterans who have lost vision in ac- impairment is the requirement for a to assist their reintegration in social tive service, because many of these in- classification system of prospective groups. Because of this, both the VA dividuals have been recently involved athletes. At present, visual classifica- and the DoD support the active in- in sports and competition. Their un- tion is strictly by central visual acu- volvement of veterans and service derstandable desire to participate and ity and peripheral visual field of view members in athletics. In fact, the VA compete is not only physically benefi- and much like the current clinical recently renewed its grant of $7.5 cial but offers them a critical affirma- grading of visual disabilities, there is million to the United States Olym- tion of their recovery, enabling them unevenness in how this translates to pic Committee (USOC) to support to experience greater, more active in- functional ability. This is partly due athletic competition and recreation volvement with their environment, to the variable impact of visual acu- for persons with disabilities and for a purposeful interaction with others, ity reductions vs field of vision losses; the athlete who is blind or visually the opportunity to compete, and a with each affecting visual function impaired.1 The VA also conducts greater sense of well-being and qual- differently. Performance differences Summer and Winter “Sports Clinics” ity of life.2-5 (See “Blinded Athlete.”) are also due to unevenness in re- for veterans with disabilities, while A wide variety of competitive sidual functional visual capabilities the DoD promotes para-sports via its sports are available to blind and vi- compared with the measured depth relationships with the U.S. Para- sually impaired athletes, many of of visual deficit.8 Table 2 lists the cur- lympics Committee at its Military which are official USOC sports (Table rent classification system of blind- Treatment Facilities and Warrior 1). In addition, there are other pop- ness, legal blindness, and low vision Transition Units. ular sports for the blind athlete not used by the United States Association

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Blinded Athlete This is the story of 27-year-old active duty U.S. Navy Lieutenant, Brad Snyder, who experienced serious facial blast wounds leaving him without sight. Undaunted by this life-changing event, he forged ahead in pursuit of excellence in athletics. His prior experience as a competitive swimmer has taken new form in his plan to get back into swimming, using adaptive technology to assist in his competi- tive swimming turns. His emphasis on athleticism as a blind person has extended to rock climbing, competing in 10K running events, and training for the 2012 Warrior Games. During his blind reha- bilitation at the Tampa Polytrauma Rehabilitation Center, Tampa, Florida, the navy lieutenant worked with occupational therapists who were impressed with his determination to succeed and the

positive impact of sports on his progress. Lieutenant Snyder re- Blinded U.S. Navy Lieutenant Brad Snyder cently completed a rehabilitation program at the VA Augusta Blind (on right), training for the 2012 Warrior Rehabilitation Center in Augusta, Georgia. Games with his brother Russell Snyder. IMAGE: U.S. NAVY PHOTO of Blind Athletes (USABA) and the and paralyses due to stroke or brain technology development. The process International Blind Sports Associa- injury. In order to overcome these is- began with working group discussions tion (IBSA). These classifications are sues, significant cross-training of pro- with a panel of experts giving a status an attempt to categorize visual loss viders is helpful, but certainly a team update in their areas of care, followed across all sports, but they provide no approach to rehabilitation is essential. by consensus discussions, designed information about how the measured to identify current challenges, their vision loss affects performance of VCE SPORTS AND RECREATION potential solutions, and any research the individual in each sport. Clearly, As part of a larger, multifaceted con- gaps that need to be addressed. the impact of visual disabilities in sensus conference held in August The sports and recreation con- sports participation is not linear and 2011, VCE expert focus groups ad- sensus group identified 4 key chal- should not be applied uniformly to dressed sports and recreation oppor- lenges for competitive sports for a each Paralympics event. This issue tunities and challenges for blind and person with vision impairment. The has been addressed by Ponchilla in a visually impaired veterans. Although first challenge was to define sports proposed model (AccesSports Model) the conference was given impetus and recreation for a person with vi- designed to adapt sports to the capa- by the visual problems experienced sual impairment. The various activi- bilities of the visually impaired in 3 in our returning Operation Enduring ties that can be considered a recreation areas: (1) targets/goals, (2) boundar- Freedom/Operation Iraqi Freedom or sport span a significant range of ies, and (3) rules.10 Presently, the IBSA veterans, the conference outcomes physical difficulty from activities such is debating changes in the classifica- were directed to the benefit of those as fishing to Olympic and other elite tion system that would place more veterans with from athletics such as alpine skiing. Fur- importance on the functional capabil- any cause, including age-related dis- thermore, the various communities ity of each athlete for each sport. eases. The consensus process was that are working with visually im- Another challenge in visually im- designed to span all agencies deliver- paired athletes each have their own paired competitive sports is that pa- ing care, including the military ser- lexicon of sports and associated im- tients with vision impairment often vices and VA, as well as to span the pairments. It was recommended that, have significant comorbidities requir- spectrum of providers, including oc- going forward, representatives of these ing additional training and modifica- cupational therapists, case managers, groups endeavor to work more closely tion for the athlete to participate in ophthalmologists, blind rehabilitation in delivering services and in develop- an event. Comorbidities can include specialists, researchers, optometrists, ing more consistent and functionally balance problems, limb amputations, and other individuals involved with usable terminology.

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Second, for blind and visually im- Table 1. Comparison of currently available Paralympics paired athletes, access to community 7 athletic facilities and services is often sports to physically vs visually disabled athletes limited. Locally, this is because there Blindness/ Amputation/ can be issues regarding consistent and Sport visual impairment paralysis reliable transportation, trained per- sonnel to provide instruction, and the Alpine skiing √ √ variability of accessible equipment. For athletes desiring to participate at a Archery √ competitive level, access to the neces- sary services is often limited. There are Biathlon √ √ simply not enough facilities, trained Canoe √ staff, and volunteers, and these are in- adequately distributed nationally to Cycling √ √ serve this need. Organizations such as the USABA and the IBSA are working Equestrian √ √ hard to expand their services for blind and visually impaired athletes, includ- Goalball √ ing the solicitation and training of vol- Judo √ unteers to act as classifiers, trainers, and mentors to prospective athletes. Nordic skiing √ √ USABA’ s Military Sports Program has been established, in collaboration with Power lifting √ the DoD, to provide services to our service members with a vision impair- Rowing √ √ ment. However, access remains an Sailing √ √ issue due to limited classifiers, facili- ties, and service locations, especially Shooting √ in rural areas. Third, adults wishing to participate Sitting volleyball √ in competitive sports while attending college or secondary education are Sled hockey √ frequently faced with a lack of main- Swimming √ √ stream physical education instructors who are trained to mentor them as Table tennis √ an athlete with a vision impairment. The “mainstreaming” of para-sports, Track & field √ √ for visual impairments will likely take time to improve. This problem may Triathlon √ √ have to do with the apparent “excep- tionalism” of para-sports, making it Wheelchair basketball √ difficult for educators and trainers Wheelchair curling √ to consider para-athletes in the same venue with the nondisabled. It is pos- Wheelchair fencing √ sible, however, that as the current conflicts wind down, the new gen- Wheelchair rugby √ eration of motivated veterans with a vision impairment will provide the Wheelchair tennis √ impetus for a “new look” at this long- Adapted from listings on the U.S. Paralympics website. standing problem within the physical

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Table 2. Visual classifications for blind and visually Richard Wacker, Wanda Washington, impaired athletes11 and James Weiland. IBSA Visual Classifications Author disclosures ­Class – No light perception in either eye up to light perception, The authors report no actual or poten- but inability to recognize the shape of a hand at any distance or in tial conflicts of interest with regard to any direction this article. ­Class – From ability to recognize the shape of a hand up to visual acuity of 20/600 and/or a visual field of < 5° in the best eye with the Disclaimer best practical eye correction The opinions expressed herein are those of the authors and do not necessarily ­Class – From visual acuity above 20/600 and up to visual acuity reflect those of Federal Practitioner, of 20/200 and/or a visual field of < 20° and > 5° in the best eye with Quadrant HealthCom Inc., the U.S. the best practical eye correction Government, or any of its agencies. USABA Recognized Low-Vision Classification This article may discuss unlabeled or ­Class B4 – From visual acuity above 20/200 and up to visual acuity investigational use of certain drugs. of 20/70 and a visual field larger than 20° in the best eye with the Please review complete prescribing in- best practical eye correction formation for specific drugs or drug combinations—including indications, Adapted from classifications listed on the USABA website. contraindications, warnings, and ad- education community. ally impaired athletes were typically verse effects—before administering Finally, although blind athletes not trained for that role. Neither were pharmacologic therapy to patients. have competed in the Paralympics for they trained to come together inter- a number of years, there are very few actively in a multidisciplinary team REFERENCES 1. VA Awards $7.5 Million to U.S. Olympic Commit- technologic advancements to modify to support a person with a vision im- tee. United States Department of Veterans Affairs sports equipment for blind or visu- pairment ambition to participate or website. http://www.va.gov/opa/pressrel/pressrelease .cfm?id=2186. Updated October 19, 2011. Accessed ally impaired athletes. The present compete in a particular sport. Solving May 14, 2012. modifications include auditory cues, this conundrum will take a paradigm 2. Marini M, Sarchielli E, Portas MF, et al. Can baseball improve balance in blind subjects? J Sports Med Phys sighted guide, enhanced visual mark- shift involving all team members. The Fitness. 2011;51(2):227-232. ings, or alterations of the target. Be- current situation, in which returning 3. Shapiro DR, Martin JJ. Athletic identity, affect, and peer relations in youth athletes with physical dis- cause of the extreme variability of the service members and veterans with abilities. Disab Health J. 2010;3(2):79-85. visual capability of each individual, vision loss desire a rapid engagement 4. Goodwin DL, Lieberman LJ, Johnston K, Leo J. Con- necting through summer camp: Youth with visual some events have been modified to in competitive sports, adds priority to impairments find a sense of community. Adapt Phys accommodate the participants using the issue and may help in stimulating Activ Q. 2011;28(1):40-55. l 5. Nakashima S, Miki Y, Miki T, Wang H, Yamasaki M. blindfolds so all participants have the the necessary change. How the number of years of sports experience and same visual acuity. Again, the work of the frequency of sports activities can influence the quality of life of people with challenges. J Hum Ergol the USABA and the IBSA to provide *Members of the Vision Center of Excel- (Tokyo). 2009;38(1):19-26. a more functional definition of visual lence Technologies Assessment Working 6. Wilson PE, Clayton GH. Sports and disability. PM R. 2010;2(13):S46-S54. impairment, in relationship to each Group: 7. by Physical Disability Group. U.S. sport, is an important step that will Jackie Britton, Anthony Candela, Paralympics website. http://www2.teamusa.org/US -Paralympics/Sports.aspx. Accessed May 16, 2012. help in this area. Once the capabilities Richard Cardillo, Zaskia Diaz-Marrero, 8. Patel DR, Greydanus DE. Sport participation by of each athlete for each sport are bet- Donald Fletcher, Duane Geruschat, physically and cognitively challenged young ath- letes. Pediatr Clin N Am. 2010;57(3):795-817. ter understood, it will be much easier Belinda Hawkins, Udobi Ikeji, William 9. Makris VI, Yee RD, Langefeld CD, Chappell AS, Sle- for the team of clinicians, therapists, Kallenberg, Natayla Merezhinskaya, menda CW. Visual loss and performance in blind athletes. Med Sci Sports Exerc. 1993;25(2):265-269. and trainers to design and study the Mia Lipner, Sue Martin, Matthew 10. Ponchilla PE. AccesSports: A model for adapting most appropriate visually adaptive ap- McMahon, Maria Nevarez, Lukus mainstream sports activities for individuals with vi- sual impairments. RE:view. 1995;27(1):5-14. proach to treatment and training. Patterson, Eli Peli, Theresa Prudencia, 11. IBSA Visual Classifications/USABA Recognized Perhaps, the most important point Mark Riccobono, Paul Schroeder, Low Vision Classification. United States Associa- tion of Blind Athletes (USABA) website. http://usaba is that those professionals who have Ronald Schuchard, Wanda Smith, Karen .org/index.php/membership/visual-classifications found themselves supporting visu- Spruill, Joan Stelmack, Nancy Strohm, /visual%20classifications/. Accessed May 14, 2012.

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