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. JUNE 2012 • FEDERAL PRACTITIONER • 11 UPDATES IN SPECIALTY CARE 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 dis orders 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 Continued on page 14 12 • FEDERAL PRACTITIONER • JUNE 2012 UPDATES IN SPECIALTY CARE Continued from page 12 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