Exercise programming for individuals with vision loss
1Department of Physical Education and Sport Teaching, Faculty of Sport Sciences, Bozok University, Yozgat, Türkiye
2Department of Sports Medicine, Faculty of Medicine, Hacettepe University, Ankara, Türkiye
3Exercise and Sport Physiology Department, Faculty of Sport Sciences, Hacettepe University, Ankara, Türkiye
Keywords: Visual impairment, vision loss, adapted physical activity, exercise, physical fitness
For individuals with vision loss (IWVL), exercise is of primary importance to optimize their functional mobility, functionality and activities of daily living. Enhancing aerobic capacity and muscle strength through exercise prescribing can help improve independent living and quality of life for IWVL. The aim of this review is to emphasize the importance of aerobic and strength exercises for underserved IWVL population by summarizing the information that will guide the basic exercise programs to improve living conditions. General guidelines for aerobic and strength exercise training for the IWVL are outlined with relevant images to contribute to build an effective exercise prescription.
Vision is a multifaceted sensory function that requires the hierarchal participation of receptors, transmission and processing structures to transform captured visual information into meaningful senses and damage along with the visual pathway results in vision loss or blindness (1). Vision impairment, also known as visual impairment (VI), is an umbrella term to describe any kind of vision loss. As seen in Table 1., the International Classification of Diseases 11 (2018) classifies VI into two core categories; distance and near presenting VI (2, 3). The prevalence of distance VI in low-and middle-income regions is estimated to be four times higher than in high-income regions (2). Accordingly, near VI prevalence is estimated to be greater in low-income regions than high-income regions (4). The growth and ageing of the world’s population are causing a significant increase in the number of people affected from VI (2). Most causes of VI are associated with ageing; however, loss of vision occurs before or at birth (congenital), during childhood, or later in life (adventitious) (5). Global prevalence of VI is 2.2 billion approximately and the leading causes of VI are uncorrected refractive errors (88.4 million), cataract (94 million), glaucoma (7.7 million), diabetic retinopathy (3.9 million), corneal opacity (4.2 million), trachoma (2 million), unaddressed presbyopia (826 million) and age-related macular degeneration (2).
VI may affect physical, cognitive, and psychological and social functioning, all important contributors to successful ageing (6). It is reported that individuals with vision loss (IWVL) demonstrate less developed motor skills, their quality of life and physical fitness levels tend to be lower than their sighted peers (7-12). They also have tendency to be overweight or obese and these problems are associated with a sedentary lifestyle (12). Reduced vision in older individuals is associated with falls and reduced performance in gait. Visual field impairment from glaucoma, contrast sensitivity, self-reported poor vision, impaired depth perception, presence of cataract and poor visual acuity are considerably related to falls, may affect gait and reduce mobility (13-17). Alternative training modalities such as virtual reality training programs are shown to be effective in improving balance and functional mobility in older individuals (18). These alternative training approaches can be tailored for IWVL. Circadian disorders are frequent in the blind especially in those who have no light perception (19, 20). This may lead disturbances in sleep/wake behaviours, alertness, mood and performance (21). Proper and well-established fitness programs can be beneficial for improvements in quality of life (e.g., increased sleep efficiency, enhancing physical and psychosocial functioning) and contribute to motor skill proficiency as well as activity of daily living (ADL) for IWVL.
|Presenting visual acuity* in the better eye|
|Distance Vision Impairment|
|· Mild||Visual acuity worse than 6/12 to 6/18|
|· Moderate||Visual acuity worse than 6/18 to 6/30|
|· Severe||Visual acuity worse than 6/60 to 3/60|
|· Blindness||Visual acuity worse than 3/60|
|Near Vision Impairment|
|· Presbyopia||Visual acuity worse than N6 or M.08 at 40 cm|
|*Snellen visual acuity or the equivalent calculated from published logarithm of the minimum angle of resolution values.|
Benefits of Exercise
It is recommended that adult individuals should engage in moderate-intensity aerobic exercise for ≥30 min.d-1 on ≥5 d.wk-1 for a total of ≥150 min.wk-1, vigorous intensity aerobic exercise for ≥20 min.d-1 on ≥3 d.wk-1 or a combination of moderate-and-vigorous-intensity aerobic exercise to achieve a total energy expenditure of ≥500-1000 MET.min.wk.-1(22). This is not only significant for general population but for IWVL as well, because aerobic exercise contributes to cardiovascular fitness and helps to reduce attaining the secondary health conditions. It is reported that blindness is associated with reduced mechanical efficiency which leads to higher energy consumption and increase in fatigue during ambulation (23, 24). Aerobic capacity depends on type and intensity of exercise which may be temporarily related to the onset of blindness and VI degree (25). Limited studies showed that blind adolescent girls aged 10-18 showed similar peak oxygen intake with their sighted counterparts (23, 24), whereas sighted adolescent boys aged 12-18 had significantly higher aerobic capacity than that of the blind boys (23). When gender was taken into consideration, aerobic capacity of blind boys was higher than blind girls and difference in aerobic capacity between congenital and non-congenital blind individuals was not statistically significant (25). It was found that children with VI had lower cardiovascular endurance than their sighted peers (26) and irrespective of gender; youth with VI had lower aerobic fitness levels (27, 28). In contrast, peak oxygen uptake (VO2peak) of blind soccer players was 51.8± 5.8 ml/kg/min and this finding suggests that blind individuals can improve their aerobic fitness regardless of their VI (29). Indeed, a unique study conducted by Saishoji and Nakata revealed that 20-min rope-guided walking (RG-walking) training increased VO2peak of IWVL by 12.4% from 30.6±10.7 ml/kg/min to 34.4±10.4 ml/kg/min by the fourth week of training (30). Based on their findings RG-walking can be recommended as an effective exercise in increasing the aerobic capacity of IWVL (Figure 1). In addition, study by Chen and Lin (32) has shown that ten weeks of rope jumping exercise improved the aerobic capacity of adolescents with VI (31).
Figure 1: Running line (Image is credited to ‘Loughborough University’ and permission is obtained)
The American Colleague of Sports Medicine (ACSM) recommends that adults should perform strength exercises for each of the major muscle groups for 2-3d.wk-1 (22). This recommendation is no different for IWVL and in order to decrease the functional limitations and improve ADL in IWVL. Muscle strength is imperative for posture and balance and reduced lower extremity muscle strength is associated with poor balance and greater risk for falls (32, 33). One of the earliest studies conducted by Wyatt and Ng reported that strength levels drop with the degree of VI and they found that congenitally blind children and children with low vision had weaker knee extensors than their sighted peers (34). Similarly, Horvat et al. reported lower muscular strength and power in adults with VI compared to sighted controls (35). On the other hand, da Silva Alves et al. found that torque values obtained for the blind athletes were higher than those reported in the study conducted by Horvat et al. (29, 35). It has been found that isometric and isokinetic strength of the knee and ankle muscles were similar in blind and sighted women (33) and Loturco et al. reported similar performances in maximal isometric strength in Paralympic and Olympics Judo athletes (36). Based on these very limited findings, it can be recommended that regular participation in exercise promotes muscular strength in IWVL.
Key Considerations for Exercise Prescription
There are no definite exercise prescriptions and guidelines for IWVL because of various degrees of VI and adjustments may be necessary according to the needs of each IWVL. Some exercise considerations can be disability specific whereas others can be similar to those of the general population. A variety of instructional strategies can be used when teaching exercises for IWVL such as demonstration, verbal instruction, and tactile teaching (5). Two very common methods used with IWVL are physical guidance and tactile modelling coupled with verbal explanations (Figure 6). Exercise programmers, fitness instructors, coaches or guide can develop goals taking into the considerations mentioned in Table 2 (5, 22, 36-40).
Aerobic exercise prescription
The aim of aerobic exercise is to improve functional mobility, and capacity and enhancing cardiovascular health in IWVL (36). Many authors highlighted that IWVL can benefit from aerobic exercises such as walking, rope jumping and aerobics despite their inability to monitor body movements visually (30, 41 ,42). Table 3 presents an example of an aerobic exercise program for IWVL. The most significant element while exercising in IWVL is using guide running techniques including assistive devices and/or sighted guides. Assistive equipment and accessories, such as guide wire, cane, running line (Figure 2), tether (Figure 3), or rope guide and individuals as sighted guides (Figure 3) are very significant (5).
As presented in Table 3 adults with VI can perform ≤20 minutes of continuous activities at a low to moderate intensity at the beginning and as the fitness level improves, work duration can be increased up to ≤60 minutes. Kobberling (23) recommended that both sighted and blind adolescents need a minimum of 30 minutes of daily activity at minimum oxygen consumption at 8 METs to attain and maintain their age-predicted normal aerobic capacity. This can be used to plan appropriate aerobic exercise for visually impaired children and adolescents with VI because they can attain aerobic fitness levels similar to those of sighted children.
|Frequency||≥ 2-3 d.wk-1 or 5-6 d.wk-1 depending on the fitness level|
|Intensity||Low to moderate (RPE=3 out of 10 or 50-65% of HRmax) and moderate to vigorous (RPE= 5-10 out of 10 or 65-85% of HRmax)|
|Duration||≥20 min.d-1 to ≥60 min.d-1|
|Type||Aerobic exercises involving large muscle groups|
|Special element||Using the auditory and tactile stimuli is significant for learning, progression and safety. Let the IWVL touch you (hand on hand approach as in Figure 6)|
|Duration||1-3 sets X 1-15 reps X 5-15 exercises depending on fitness level|
|Type||Strength exercises involving major muscle groups in the chest, shoulders, back, hips, legs, arms and abdomen.|
|RPE: rating of perceived exertion; HRmax: maximal heart rate; IWVL: individuals with vision loss.|
Figure 2: A blind girl running with running line (Image is credited to ‘Loughborough University’ and permission is obtained)
Figure 3: A blind runner and sighted guide with a tether
Figure 4: The sighted rider (pilot) with a blind cyclist
Figure 5: Blind person walking on a motorized treadmill. As seen in the figure, a treadmill with handrail supports should be preferred and rope can be tied up to either end of handrails behind the blind person for safety.
Resistance exercise prescription
According to the ACSM, strength exercise training may improve or maintain bone mass, muscle mass, glucose tolerance, musculotendinous integrity, the ability to carry out the ADL, fat free mass and resting metabolic rate of daily living (36). The most significant element is to make sure that IWVL performing the exercises with the strict posture and correct technique. Equipment familiarization and supported exercises are also of utmost importance. Strength exercise training for IWVL resembles those of healthy individuals.
Figure 6: Instructor is demonstrating a swimming technique with hand on hand approach
Figure 7: Medicine ball side twists. Blind person is exercising with medicine ball to increase muscular strength and endurance.
The strength exercise training for IWVL should warrant improved physical functioning and increased core and dynamic strength, improved postural balance and reduced risk of falls. Strength is one of the components of physical functioning and strength training improves functionality in IWVL. Additionally, strength exercise training will strengthen key muscles needed for ADL and prevent injuries from muscle imbalances because it is reported that IWVL adopts compensatory postural changes in order to adjust the centre of gravity (42). It is important to adapt and structure the program according to strength level and loss of visual sense in IWVL (Table 3). For this, resistance machines with support base such as smith machine can be safer for IWVL compared to free weights. Furthermore, training load to determine 1 repetition maximum (1RM) values from multiple repetitions can be applied to adopt the strength exercise program (43). Primary focus of the initial program should be on improving the strength and endurance of each major muscle groups; the progression of the strength exercise program should be arranged week to week with the focus on anatomical adaptation to balance and strengthen the musculoskeletal system. Anatomical adaptation is the most basic and fundamental method and light resistance with high repetitions circuit weight training are recommended (44). Following the anatomical adaptation phase in strength exercise training, the exercise program should be individualized addressing the needs and desires of the IWVL.
Figure 8: Dumbbells for the development of shoulder strength. This is also a good example including tactile demarcations as the blind person leaning against a wall. Additionally, blind person is performing dumble shoulder press exercise
Improving aerobic and strength conditioning of IWVL can help advancing independent living and quality of life and can allow them to perform ADL without getting exhausted quickly. Adapting exercise to this particular population requires specific exercise guidelines and consideration of VI characteristics. The variability of VI degree demonstrates the importance of an individual approach determining the appropriate exercise program. Life time blindness (congenital vs acquired), degree of VI, VI causes, gender and age are key factors when designing exercise plan for this special population. Maintaining a healthy body weight, increasing strength and improving functional mobility means a better quality of life for IWVL. Creating an adaptive exercise by trainers, reviewing and improving the program to achieve requested goals will be of great benefit to this particular population.
Cite this article as: Esatbeyoglu F, Karacoban L, Akin S, Donmez G. Exercise programming for individuals with vision loss. Turk J Sports Med. 2022, 57(4):213-9; 2022 https://doi.org/10.47447/tjsm.0690
Concept FE; Design FE; Supervision SA, LK, GD; Materials FE; Data Collection and/or Processing FE; Analysis and Interpretation All authors; Literature Review FE; Writing Manuscript FE; Critical Reviews All authors.
The authors declared no conflicts of interest with respect to authorship and/or publication of the article.
The authors received no financial support for the research and/or publication of this article.
- Martin MBC, Santos-Lozano A, Martin-Hernandez J, Lopez-Miguel A, Maldonado M, Baladron C, et al. Cerebral versus ocular visual impairment: the impact on developmental neuroplasticity. Front Psychol. 2016;7:1958. DOI: 10.3389/fpsyg.2016.01958
- Bourne RR, Flaxman SR, Braithwaite T, Cicinelli M, Das A, Jonas JB, et al. Magnitude, temporal trends, and projections of the global prevalence of blindness and distance and near vision impairment: a systematic review and meta-analysis. Lancet Glob Health. 2017;5(9):e888-97.
- World Health Organization. Blindness and Vision Impairment; (cited 2021 Jul 7). https://www.who.int/news-room/fact-sheets/detail/blindness-and-visual-impairment.
- Bourne R, Steinmetz JD, Flaxman S, Briant PS, Taylor HR, Resnikoff S, et al. Trends in prevalence of blindness and distance and near vision impairment over 30 years: an analysis for the global burden of disease study. Lancet Glob Health. 2021;9(2):e130-43.
- Lieberman LJ and Runyan M. Visual Impairments and Deafblindness. In Block M, Ed. A Teacher’s Guide to Including Students with Disabilities in General Physical Education: Including Stdents with Disabilites in Sports and Recreation. Baltimore: Paul H. Brooks; 2016, p. 231-35.
- Swenor BK, Lee MJ, Varadaraj V, Whitson HE, Ramulu PY. Aging with vision loss: a framework for assessing the impact of visual impairment on older adults. Gerontologist. 2020;60(6):989-95. DOI: 10.1093/geront/gnz117
- Bakke HA, Cavalcante WA, de Oliveira IS, Sarinho SW and Cattuzzo MT. Assessment of motor skills in children with visual impairment: a systematic and integrative review. Clin Med Insights Pediatr. 2019;13:1179556519838287. DOI: 10.1177/1179556519838287
- Chandrasekaran N, Harlow S, Moroi S, Musch D, Png Q, Karvonen-Gutierrez C. Visual impairment at baseline is associated with future poor physical functioning among middle-aged women: the study of women's health across the nation, Michigan site. Maturitas.2017;96:33-8. DOI: 10.1016/j.maturitas.2016.11.009
- Esatbeyoglu F, in-İsler A. Gender differences in postural balance, physical activity level, BMI, and body composition in athletes with visual impairment. Br J Vis Impair. 2021;https://doi.org/10.1177/02646196211009921 DOI: 10.1177/02646196211009921
- Giese M, Teigland C, Giessing J. Physical activity, body composition, and well-being of school children and youths with visual impairments in Germany. Br J Vis Impair. 2017;35(2):120-9. DOI: 10.1177/0264619617689905
- Hallemans A, Ortibus E, Truijen S, Meire F. Development of independent locomotion in children with a severe visual impairment. Res Dev Disabil. 2011;32(6):2069-74. DOI: 10.1016/j.ridd.2011.08.017
- Augestad LB and Jiang L. Physical activity, physical fitness, and body composition among children and young adults with visual impairments: A systematic review. Br J Vis Impair. 2015;33(3):167-82. DOI: 10.1177/0264619615599813
- Grisafe II DJ, Varma R, Burkemper BS, Xu BY, Torres M, Fairbrother-Crisp A, et al. Impact of visual field loss on vision-specific quality of life in african americans: the african american eye disease study. Am J Ophthalmol. 2021;229:52-62. DOI: 10.1016/j.ajo.2021.02.008
- Ivers RQ, Cumming RG, Mitchell P, Attebo, K. Visual impairment and falls in older adults: the blue mountains eye study. J Am Geriatr Soc. 1998;46(1):58-64. DOI: 10.1111/j.1532-5415.1998.tb01014.x
- Jones RR, Somoskeöy T, Chow-Wing-Bom H, Crabb DP. Seeing other perspectives: evaluating the use of virtual and augmented reality to simulate visual impairments (OpenVisSim). NPJ Digit Med. 2020;3:32. DOI: 10.1038/s41746-020-0242-6
- Medeiros FA. Glaucoma associated with changes in gait over time. JAMA Ophthalmol. 2021;139(10):1060-1. DOI: 10.1001/jamaophthalmol.2021.2621
- Ramulu PY, Mihailovic A, Jian-Yu E, Miller RB, West SK, Gitlin LN et al. Environmental features contributing to falls in persons with vision impairment: The role of home lighting and home hazards. Am J Ophthalmol. 2021;230:207-15. DOI: 10.1016/j.ajo.2021.04.022
- Donath L, Rössler R, Faude O. Effects of virtual reality training (exergaming) compared to alternative exercise training and passive control on standing balance and functional mobility in healthy community-dwelling seniors: a meta-analytical review. Sports Med. 2016;46(9):1293-309. DOI: 10.1007/s40279-016-0485-1
- Hartley S, Dauvilliers Y, Quera-Salva MA. Circadian rhythm disturbances in the blind. Curr Neurol Neurosci Rep. 2018;18(10):65. DOI: 10.1007/s11910-018-0876-9
- Lockley SW, Arendt J, Skene DJ. Visual impairment and circadiam rhythm disorders. Dialogues Clin Neurosci. 2007;9(3):301-14. DOI: 10.31887/DCNS.2007.9.3/slockley
- Allen AE. Circadian rhythms in the blind. Curr Opin Behav Sci. 2019;30:73-9. DOI: 10.1016/j.cobeha.2019.06.003
- Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte MJ, Lee IM, et al. American college of sports medicine osition stand: quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43(7):1334-59. DOI: 10.1249/MSS.0b013e318213fefb
- Kobberling G, Jankowski LW, Leger L. The relationship between aerobic capacity and physical-activity in blind and sighted adolescents. J Vis Impair Blind. 1991;85(9):382-4. DOI: 10.1177/0145482X9108500909
- Williams CA, Armstrong N, Eves N, Faulkner A. Peak aerobic fitness of visually impaired and sighted adolescent girls. J Vis Impair Blind. 1996;90(6):495-500. DOI: 10.1177/0145482X9609000607
- Moura e Castro J. Costa O, Freitas F. Evaluation of the aerobic capacity of blind people, by direct VO2 maximal measurement. Rev Port Cardiol;1992;11(6):525-9.
- Lieberman LJ, McHugh E. Health-related fitness of children who are visually impaired. J Vis Impair Blind. 2001;95(5):272-87. DOI: 10.1177/0145482X0109500503
- Furtado Morato MP, Potenza M, Gutierrez GL. Health-related physical fitness among young goalball players with visual impairments. J Vis Impair Blind. 2016;110(4):257-67. DOI: 10.1177/0145482X1611000405
- Jankowski L, Evans J. The exercise capacity of blind children. J Vis Impair Blind. 1981;75(6):248-51. DOI: 10.1177/0145482X8107500605
- da Silva Alves E, de Aquino Lemos V, Rosa JPP, da Silva A, Gavea J, da Rocha EA, et al. Profile of aerobic fitness and muscle power of athletes on the Brazilian national Paralympic five-a-side football team. Revista Brasileira de Educação Física e Esporte. 2019;33(3):345-52. DOI: 10.11606/1807-5509201900030345
- Saishoji H, Nakata H. Endurance training with an adapted device in the visually impaired. In: Yabe K, Kusano K, Nakata H. eds. Adapted Physical Activity: Health and Fitness. Tokyo: Springer-Verlag, 1994. p. 176-81. DOI: 10.1007/978-4-431-68272-1_28
- Wagner M O, Haibach PS, Lieberman LJ. Gross motor skill performance in children with and without visual impairments-research to practice. Res Dev Disabil. 2013;34(10):3246-52. DOI: 10.1016/j.ridd.2013.06.030
- Chen CC, Lin SY. The impact of rope jumping exercise on physical fitness of visually impaired students. Res Dev Disabil. 2011;32(1):25-9. DOI: 10.1016/j.ridd.2010.08.010
- Giagazoglou P, Amiridis IG, Zafeiridis A, Thimara M, Kouvelioti V, Kellis E. Static balance control and lower limb strength in blind and sighted women. Eur J Appl Physiol. 2009;107(5):571-9. DOI: 10.1007/s00421-009-1163-x
- Wyatt L, Ng GY. The effect of visual impairment on the strength of children's hip and knee extensors. J Vis Impair Blind. 1997;91(1):40-6. DOI: 10.1177/0145482X9709100107
- Horvat M, Ray C, Croce R, Blasch B. A comparison of isokinetic muscle strength and power in visually impaired and sighted individuals. Isokinet Exerc Sci. 2004;12(3):179-83. DOI: 10.3233/IES-2004-0171
- Loturco I, Nakamura FY, Winckler C, Braganca JR, da Fonseca RA, Moraes-Filho J, et al. Strength-power performance of visually impaired Paralympic and Olympic judo athletes from the Brazilian national team: a comparative study. J Strength Cond Res. 2017;31(3):743-9. DOI: 10.1519/JSC.0000000000001525
- American Colleage of Sports Medicine. ACSM's Guidelines for Exercise Testing and Prescription. In: Riebe D, Ehramn, JK, Liguori G, Magal M, Eds. Philadelphia: Wolter’s Kluwer; 2018, p. 55-8.
- Pan CW, Liu H, Sun HP, Xu Y. Increased difficulties in managing stairs in visually impaired older adults: a community-based survey. PLoS One. 2015;10(11):e0142516. DOI: 10.1371/journal.pone.0142516
- Squarcini CF, Pires ML, Lopes C, Benedito-Silva AA, Esteves AM, Cornelissen-Guillaume G, et al. Free-running circadian rhythms of muscle strength, reaction time, and body temperature in totally blind people. Eur J Appl Physiol.2013;113(1):157-65. DOI: 10.1007/s00421-012-2415-8
- Zhu MM, Lai JSM, Choy BNK, Shum JWH, Lo ACY, Ng ALK, et al. Physical exercise and glaucoma: a review on the roles of physical exercise on intraocular pressure control, ocular blood flow regulation, neuroprotection and glaucoma-related mental health. Acta Ophthalmol. 2018;96(6):e676-e691. DOI: 10.1111/aos.13661
- Ponchillia SV, Powell L L, Felski KA, Nicklawski MT. The effectiveness of aerobic exercise instruction for totally blind women. J Vis Impair Blind. 1992; 86(4): 174-7. DOI: 10.1177/0145482X9208600404
- Fioco EM, Verri ED, Zanella CAB, Bidurin CP, Tonello MGM. Relationship between postural imbalance and cervical disability in visually impaired individuals. Revista Brasileira em Promocao da Saude. 2016;29(4):525-32. DOI: 10.5020/18061230.2016.p525
- Landers J. Maximum based on reps. NSCA J. 1985; 6:60-1. DOI: 10.1519/0744-0049(1984)006<0060:MBOR>2.3.CO;2
- Lin J D, Chen TH. Diversity of strength training methods: a theoretical approach. Strength Con J. 2012;34(2):42-9. DOI: 10.1519/SSC.0b013e31822f73ea