Vision Impairment in children with Cerebral Palsy
One in every ten children with Cerebral Palsy (CP) presents with severe visual impairment and 75-90% present with some degree of visual impairment. Associated conditions should always be considered when treating a child with CP to ensure a holistic approach is taken. Read more about some of these conditions on the Physiopedia page http://www.physio-pedia.com/Cerebral_Palsy_Association_Conditions. Cortical visual impairment is an associated condition of CP and has been identified as one of the primary causes of visual impairment in children. 
Cortical Visual Impairment (CVI)
CVI is defined as visual loss due to damage caused to the central nervous system, more specifically the occipital lobe of the brain. It is therefore understandable that it is commonly associated with CP, which shares similar etiology (i.e. hypoxia, increased intracranial pressure, head injury etc.)  As with any injury to the brain CVI may gradually improve due to neural plasticity, especially in the first year of life. Aspects of visual stimulation should form an integral part of the assessment and treatment done by the multidisciplinary team (MDT).  A formal vision assessment should always be performed by a specialist to confirm the diagnosis and prescribe appropriate treatment.
Vision and normal development
- Gross motor development
- Fine motor development
- Cognitive development
- Communication and language development
- Social interaction Self-help skills
- Play skills
Visual impairment consequently affects patients on all the levels of the International Classification of Functioning, Disability and Health (ICF). A MDT approach is essential to maximise the patient’s potential. For more information on the ICF refer to http://www.physio-pedia.com/ICF_and_RPS_within_Cerebral_Palsy. Motor development relies greatly on vision to encourage children to move. Curiosity and motivation to explore a visual stimulus assist with the development of head control, crawling, walking and learning to manipulate objects. 
CVI and physiotherapy
As previously mentioned a formal diagnosis should always be made by a specialist. Unfortunately in many developing countries it often takes months to years for a patient to get an appointment. In the meantime it is important to start stimulating the child’s residual vision or use non-visual stimulation during treatment. The goal is to allow the child to fixate/locate an object, track it, reach for it and ultimately take it to the mouth for exploration.
- Confirm with the caregivers if a specialist has been consulted. If not refer them to the appropriate person.
- Treatment should take place in a quiet area in order to minimise distractions.
- Ensure suitable lighting, preferably adjustable lights.
- Perform a comprehensive subjective and objective assessment with the caregivers.
- Involve the caregivers as much as possible during the session. Children often respond best to their caregivers’ faces as part of normal development.
A child with CP has to overcome multiple factors to maintain a stable position. The child should be supported in order to focus on visual input only. Supported sitting is therefore a good position to start visual stimulation.  Different positions can be implemented as the child progresses.
3. Introduction of visual stimulus:
Attention should be given to the caregivers’ observation. They will often note that children tend to stare at lights (as observed in 60% of children with CVI ), respond to high contrast colours or objects illuminated by light in a darkroom and they will often be aware in which area of the visual field the child responds best to. The following low cost objects can be used during treatment:
using light to iluminat objects
crowding of toys
4. The patient should be allowed adequate time to process and respond to the visual stimulus as this is often delayed.  It is also very important to explain this to the caregivers as they often assume that the child has lost interest and therefore remove the stimulus. It is commonly seen that children turn their head away in order to apply or use their more developed peripheral vision.
5. Use movement as children with CVI may be able to locate moving objects faster.
6. Use tactile and verbal stimulation to assist with the location and identification of objects.
7. Start with shorter treatment sessions as children may become overstimulated and irritated due to fatigue and/or frustration. (Recommended duration is less than 12 minutes, twice per day, 5 days a week for one year.) 
8. Give appropriate education and home programme. This may be in the form of an individualised family service plan or programme. The family centred approach is essential.
Education and Home Programme
Educating the care givers is essential in ensuring compliance with the prescribed home programme and subsequent carry-over of learning. The caregivers should be thoroughly educated on the diagnosis and implications of CVI. They should understand the significance of neural plasticity and what it can mean for their child’s vision.
Caregivers often do not realise or understand the anxiety and fear of a child with a visual impairment and preparation strategies should be implemented to try to overcome this.
- Comply with the exercises as prescribed above.
- Try to incorporate stimulation into activities of daily living (ADLs), for example before changing the nappy the child can be allowed to look and touch the clean nappy.
- Try to create a quiet and calm environment for the child when doing stimulation exercises. Don’t leave the radio or television on throughout the day as background noise can overstimulate and irritate them.
- Prepare the child for any change in position or touching by verbally explaining to him/her what is going to happen and start with a firm touch to reassure them.
- Announce to the child when you enter and leave the room as to not scare them. Siblings and other members of the household should be encouraged to do the same.
- Allow the child to participate in ADL. This will assist the child to associate sounds or tactile input with activities. For example, caregivers can talk about the sound of running water before bath-time or touch their food before feeding.
- Use tactile stimulation for learning, by making use of different textures and temperatures to develop sensory skills. The child can also touch the caregivers’ faces for bonding or play during these activities.
Children with CP have many facets that need to be taken into consideration during assessment and treatment. The crucial role vision plays in development cannot be ignored and should therefore not be overlooked by the treating physiotherapist.
- Physio-pedia, Cerebral Palsy Association Conditions. [/www.physio-pedia.com/Cerebral%20Palsy%20Association%20Conditions http://www.physio-pedia.com/Cerebral_Palsy_Association_Conditions] (last accessed 26/10/2016)
- Swift SH, Davidson RC, Weems LJ. Cortical Visual Impairment in Children: Presentation Intervention, and Prognosis in Educational Settings. Teaching Exceptional Children Plus. 2008;4:2-14.
- Carden SM, Good WV. Cortical Visual Impairment. Handbook of pediatric neuro-ophthalmology. P247-254
- RNIB. Southwell, C. Haigh, K. Visual Impairment and Physiotherapy. November 2010:
- RNIB. Visual Impairment and Occupational Therapy. March 2011
- RNIB. Bell, I. & Bell, J. Visual Impairment and Speech and Language Therapy. July 2011
- Physio-pedia, ICF and RPS within CP. [/www.physio-pedia.com/ICF%20and%20RPS%20within%20Cerebral%20Palsy http://www.physio-pedia.com/ICF_and_RPS_within_Cerebral_Palsy] (last accessed 27/10/2106)