CVI for Physical Therapists (PTs)

Written by: Karen Barrows, DPT, MEd, TVI, MHS, CCVI

What is CVI?

Cerebral/cortical visual impairment (CVI) is a brain-based visual impairment caused by damage or interruption to the visual processing areas of the brain. With CVI, the brain has difficulty recognizing and making sense of the visual world. CVI impacts every aspect of life. The CVI visual behaviors are a framework for understanding the impact of CVI on access and is rooted in current CVI research.

CVI is the leading cause of childhood blindness and low vision, but it is alarmingly underdiagnosed. Less than 20% of kids in the US have a CVI diagnosis. CVI often co-occurs with neurological, neurodevelopmental, or genetic conditions. Those with healthy eyes and without other conditions can still have CVI.

How might CVI impact access to physical therapy?

There is no aspect of a student’s development that is not impacted by CVI. Movement, balance, coordination, and motivation to move are impacted throughout a student’s life. The motivation to move is heavily influenced by visual skills. If a student isn’t able to visually regard and recognize an item to move toward, they require alternate methods of motivation to support their movement development. The physical therapist (PT) should be knowledgeable about all visual impairments, including CVI. CVI is often associated with children having other neurological conditions including, cerebral palsy (CP), epilepsy, developmental delays, and genetic disorders.

When might you suspect a student has CVI within your work as a pyhsical therapist?

CVI has diverse manifestations and no two individuals with CVI are exactly alike. Here some examples of indicators and observations that might lead to suspecting CVI:

Fixate on moving ceiling fans, strong light sources, and gently moving items such as curtains
Look above your eyes or seemingly “past” your face when turned in your direction
Be more cautious than expected when walking around obstacles or negotiating height differences such as steps
Bump into obstacles and show reduced awareness of objects in their lower, upper, left, and/or right visual fields; appear clumsy and often run into things
Demonstrate a significant difference in mobility skills when the environment is more busy or complex. For example, navigating more easily down a quiet hallway or in a familiar area, but hesitating, bumping into walls or objects, or being generally clumsy when there is more movement, sound, and variable lighting of surfaces around them
Be significantly more visually aware of familiar, colorful, or lighted objects beyond the age expected for this behavior
Refuse or resist to negotiate changes in surfaces or heights, such as ramps, stairs, and flooring/ground with different surfaces/colors; may sit down to navigate over changes in surface
Not look at the floor or look excessively at their feet and floor when walking
Demonstrate using their visual skills more successfully when given proper positioning for their physical needs
Being more alert and engaged during sessions when in a quiet setting versus a noisy setting
Being more motivated to move toward a brightly colored, lighted, familiar, and/or moving object
Respond to directions and sounds by listening more than looking
Become fatigued more quickly than expected and avoid engaging in the activity
Prefer to mainly touch items or explore tactually instead of looking
Take longer than expected to notice an item that is presented and then to move toward it

Two side-by-side images of a very cluttered and visually complex therapy space, with multicolored tiles, bouncy balls stacked high, and toys scattered. — Example of a very cluttered and visually complex therapy space that may be overwhelming for a child with CVI

Learn more about when to suspect CVI.

What strategies might be helpful to use in the PT setting with students with CVI?

All interventions, instructional approaches, and accommodations must be driven by comprehensive assessment that meet the student’s individual needs to access learning and the environment. Below are a few ideas to inspire inquiry.

Environmental adaptations

Reduce clutter, multiple colors in the room, extraneous movement, and bright light sources in your setting.
Limit decorations in at least one space of your center or have relatively blank walks available for the student to face during sessions.
Dim lights if the student is showing fatigue or light sensitivities.
Work with the student in a quieter space.

Instructional and material adaptations

Provide objects that are most engaging for the student. Use motivators specific to the student (e.g. show the student colorful Sonic videos if interested in this topic).
Use light and color intentionally based on the specific needs of the student. For example, the student may be motivated to look at, reach for, or walk toward items with bright colors, focused light, that are simple in presentation, and familiar.
Provide high contrast objects against a plain background.
Provide a multi-sensory approach, where the student can use the sensory channel they prefer—for example, tactile, kinesthetic, or auditory.
Limit competing sensory input if not tolerated (e.g. if the student cannot look and listen at the same time, avoid sounds or provide each input separately).
Provide verbal descriptions and prompting of task, space, and items.
Provide ample opportunities for tactile exploration and support.

Therapeutic adaptations

When facilitating a child’s posture, balance, and mobility, expect that the student with CVI will be more challenged to use their vision. Plan for more supports such as touch, light, movement, and sound to get their attention with less reliance on their vision.
Be aware of the signs of visual and overall fatigue in the students with CVI with whom you are working. Each show fatigue in their own way. Visual fatigue may present as closing their eyes, putting their head down, stopping all activities, and/or showing behavioral changes. Build in proactive rest breaks and non visual access to the task.
Introduce yourself and wear a unique item that distinguishes you from others (e.g. Matt always wears a green watch). Many with CVI have face blindness and cannot identify a person by looking at their face. Do not expect the student to look at your face.
Present objects in the student’s best visual fields as noted in their CVI assessment.
Give the student time to process looking toward an object and also process what it is. Limit extraneous noises and directions during this time.

Yellow obstacle course ladder on black floor

Collaboration ideas

Collaboration is key to the success of physical therapy intervention!

Offer other disciplines the best physical support possible to maximize the student’s alertness, engagement, and visual access during their sessions and classes.
Share with other disciplines, especially the student’s OT, TVI, O&M, and other vision specialists if you note any visual differences that may indicate CVI or other visual issues.
Collaborate with the student’s OT, TVI, O&M, and other vision specialists about strategies to use in your PT sessions.
Co-treatment sessions with a TVI, O&M, or OT are helpful to determine how to modify your sessions and to understand the impact they have on your student’s use of vision and development.

A collage of supports: a seat, angled cushion, tactile object, and pillow. — Examples of positioning and physical support tools that can be used by other disciplines.

Explore more resources on CVI and PT

Note to readers: This article is meant as an overview and brief introduction to CVI, a deep and complex condition with diverse manifestions. It is important to remember that all children with CVI have different needs. The recommendations and suggestions are ideas for a starting point. There is not one size fits all approach for CVI, and interventions and strategies must be match to the student’s individualized needs and comprehensive assessment results.

Explore CVI overviews for various disciplines in our CVI Educator Toolbox.

Karen Barrows DPT, MEd, TVI, MHS, CCVI

Karen is a Physical Therapist with over 35 years of experience with most being in pediatrics with a specialty in children with multiple impairments including vision. She is also a Teacher of Students with Visual Impairment with certification in Cerebral/Cortical Visual Impairment. She works with the Perkins’ CVI Center in assessments of students with CVI.