Development of an integrated telerehabilitation model in children with cerebral visual impairment in South India during the COVID-19 pandemic - A pilot study.

Purpose: Coronavirus disease 2019 (COVID-19) pandemic affected the in-person rehabilitation/habilitation services in families with children with cerebral visual impairment (CVI) in India. This study aimed to develop a structured and family-centered telerehabilitation model alongside conventional in-person intervention in children with CVI to observe its feasibility in the Indian population. Methods: This pilot study included 22 participants with a median age of 2.5 years (range: 1-6) who underwent a detailed comprehensive eye examination followed by functional vision assessment. The visual function classification system (VFCS) was administered to the children and the structured clinical question inventory (SCQI) to the parents. Every participant underwent 3 months of telerehabilitation including planning, training, and monitoring by experts. At 1 month, the parental care and ability (PCA) rubric was administered to the parents. After 3 months, in an in-person follow-up, all the measures were reassessed for 15 children. Results: After 3 months of Tele-rehabilitation there were significant improvements noted in PCA rubric scores (P<0.05). Also, statistically significant improvements were noted in functional vision measured using SCQI and VFCS scores (P<0.05) compared to baseline. Conclusion: The outcomes of the study provide the first steps towards understanding the use of a novel tele-rehabilitation model in childhood CVI along-side conventional face-to-face intervention. The added role of parental involvement in such a model is highly essential.

Parental perception of facilitators and barriers to activity and participation in an integrated tele-rehabilitation model for children with cerebral visual impairment in South India - A virtual focus group discussion study.

Purpose: This study utilized virtual focus group discussions to document the facilitators and barriers reported by the parents as part of the tele-rehabilitation service delivery model in India. Methods: This study included 17 participants who were enrolled into the Tele-rehabilitation program (16 mothers, 1 father) and the virtual focus group discussion (V-FGD) were conducted through a WhatsApp video call. Three V-FGDs were conducted involving two moderators and a note taker. The V-FGD, focused at extracting the perceptions of parents pertaining to facilitators, barriers and coping mechanisms to barriers related to the tele-rehabilitation model. Results: Thematic analysis resulted in four themes for barriers that included: family and support, time, parent and care taker, child and place of living related; facilitators reported included: continuous monitoring, accessibility to professional services, provision of resource materials and parental empowerment. Themes "family and support" and "child" were most reported by parents with children >3 years and ≤3 years respectively. Finally, the barriers and facilitators were aligned with the chapters and codes of International Classification of Functioning, children and youth version (ICF-CY) environment and personal factors. Conclusion: This V-FGD highlights the importance of parental-centred and structured Tele-rehabilitation among children with CVI in India. The outcome of this study opens avenues for creating effective intervention.

Visual function assessment, ocular examination, and intervention in children with developmental delay: A systematic approach - Part 2.

In India, there is increasing number of children with development delay and vision impairment with or without additional disabilities due to prematurity, brain damage, cerebral palsy, or genetic syndromes. Despite initiatives from Government of India, early intervention for these children remains a challenge across the country due to lack of trained professionals and appropriate resources. This paper describes the developmental screening tools, intervention aspects including Individualized Education Plan, procedures for handling children with cerebral visual impairment, team approach, and guidelines derived from the inputs of experts in vision rehabilitation centers of premier eye institutes in India.

Understanding low functioning cerebral visual impairment: An Indian context.

For several reasons, cerebral visual impairment (CVI) is emerging as a major cause of visual impairment among children in the developing world and we are seeing an increasing number of such children in our clinics. Owing to lack of early training about CVI and it being a habilitation orientated subject, we need to become equipped to optimally help the affected children. In this paper we have explained our pragmatic approach in addressing children who present with low functioning CVI. Initially we explain briefly, how vision is processed in the brain. We then present what should be specifically looked for in these children in regular clinics as a part of their comprehensive ophthalmic examination. We discuss the process of functional vision evaluation that we follow with the help of videos to explain the procedures, examples of how to convey the conclusions to the family, and how to use our findings to develop intervention guidelines for the child. We explain the difference between passive vision stimulation and vision intervention, provide some common interventions that may be applicable to many children and suggest how to infuse interventions in daily routines of children so that they become relevant and meaningful leading to effective learning experiences.

Visual function assessment, ocular examination, and intervention in children with developmental delay: A systematic approach. Part 1.

Children with special needs form a unique subset with regards to visual function and examination techniques needed to assess them. With more awareness among the general public, neurologists, and pediatricians, these children are referred for assessment to the ophthalmologist or optometrist and sometimes even to the rehabilitation professional at an early age. This clinical practice guideline and review gives a systematic approach for examining the visual functions of a child with special needs. It outlines the procedures to be followed with equipment needed in clinical practice. Functional vision assessment guidelines are also included. This is the first part in a two-part series, with the first part presenting clinical examination guidelines and the second presenting intervention and vision enhancement techniques.

Current Understanding of What Infants See.

The current understanding of what infants see varies greatly among healthcare and education specialists. Even among ophthalmologists and pediatric neurologists in charge of clinical examinations of infants, opinions vary on what infants perceive, recognize, and use for communication and learning. It is, therefore, of interest to review publications from several specialties to learn whether new information is available on the development of visual functions and use of vision. Ten percent of total publications on this subject are reviewed here based on the usefulness of their content for improving early diagnosis and intervention of vision disorders in infants.

Impact of low vision care on reading performance in children with multiple disabilities and visual impairment.

BACKGROUND: Lack of evidence in literature to show low vision care enhances the reading performance in children with Multiple Disabilities and Visual Impairment (MDVI). AIM: To evaluate the effectiveness of Low Vision Care intervention on the reading performance of children with MDVI. MATERIALS AND METHODS: Three subjects who were diagnosed to have cerebral palsy and visual impairment, studying in a special school were recruited for the study. All of them underwent detailed eye examination and low vision care evaluation at a tertiary eye care hospital. A single subject multiple baseline (study) design was adopted and the study period was 16 weeks. The reading performance (reading speed, reading accuracy, reading fluency) was evaluated during the baseline phase and the intervention phase. The median of all the reading parameters for each week was noted. The trend of the reading performance was graphically represented in both the phases. RESULTS: Reading speed increased by 37 Word per minute, 37 Letters per minute and 5 letters per minute for the subject 1, 2 and 3 respectively after the intervention. Reading accuracy was 84%, 91% and 86.4% at the end of the baseline period and 98.7%, 98.4% and 99% at the end of 16 weeks for subject 1, 2 and 3 respectively. Average reading fluency score was 8.3, 7.1 and 5.5 in the baseline period and 10.2, 10.2 and 8.7 in the intervention period. CONCLUSION: This study shows evidence of noticeable improvement in reading performance of children with MDVI using a novel study design.

An inertial sensor-based system to develop motor capacity in children with cerebral palsy.

Learning to communicate with alternative augmentative communication devices can be difficult because of the difficulty of achieving controlled interaction while simultaneously learning to communicate. What is needed is a device that harnesses a child's natural motor capabilities and provides the means to reinforce them. We present a kinematic sensor-based system that learns a child's natural gestural capability and allows him/her to practice those capabilities in the context of a game. Movement is captured with a single kinematic sensor that can be worn anywhere on the body. A gesture recognition algorithm interactively learns gesture models using kinematic data with the help of a nearby teacher. Learned gesture models are applied in the context of a game to help the child practice gestures to gain better consistency. The system was successfully tested with a child over two sessions. The system learned four candidate gestures: lift hand, sweep right, twist right and punch forward. These were then used in a game. The child showed better consistency in performing the gestures as each session progressed. We aim to expand on this work by developing qualitative scores of movement quality and quantifying algorithm accuracy on a larger population over long periods of time.