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ABSTRACT

Siegal, Irwin M.; Murphy, Thomas J.Postural Determinants in the Blind. Final Report.Illinois Visually Handicapped Inst., Chicago, Ill.Social and Rehabilitation Service (DHEW) ,Washington, D.C. Div. of Research and DemonstrationGrants.Aug 70113p.

EDRS Price MF-$0.65 HC-$6.58Body Image, *Exceptional Child Research, Exercise(Physiology), *Human Posture, Physical Therapy,*Visually Handicapped, *Visually HandicappedMobility, *Visually Handicapped Orientation

The problem of malposture in the blind and itsattect on orientation and travel skills was explored. A group of 45students were enrolled in a standard 3-month mobility trainingprogram. Ea,_:h student suite red a postural problem, some compounded bysevere orthopedic and/or neurological deficit. All subjects weregiven complete orthopedic and neurological examinations as well as abattery of special psychometric tests. Postural problems werediagnosed and treated by a variety of therapeutic techniques, somenewly describd, including specialized exercise, splintage, andpostural physical education programs. Improvement evaluation (bymotion picture photography) was made before, during and after the3-month program. The hypothesis tested was that improvement inposture contributed to improvement in mobility. The final resultsindicated such a correlation to exist. One implication is thatpostural training plays an important role in the development ofmobility skills and thus in the total rehabilitation of the blind.(Author)

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FINAL REPORT

EC031990

POSTURAL DETERMINANTS IN THE BLIND(The Influence of Posture on Mobility and Orientation)

IRWIN M. SIEGEL, M.D., Chief Investigator

THOMAS J. MURPHY, Project Director

DEPARTMENT OF CHILDREN AND FAMILY SERVICESILLINOIS VISUALLY HANDICAPPED INSTITUTE

1151 South Wood, Chicago, Illinois

August, 1970

U.S. DEPARTMENT OF HEALTH. EDUCATION& WELFARE

DFFICE OF EDUCATIONTHIS DOCUMENT HAS BEEN REPRODUCEDEXACTLY AS RECEIVED FROM THE PERSON ORORGANIZATION ORIGINATING IT. POINTS OFVIEW OR OPINIONS STATED DO NOT NECES-SARILY REPRESENT OFFICIAL OFFICE OF EDU-CATION POSITION OR POLICY

This investigation was supported, in part, by Research GrantNo. RD-3512-SB-70-C2 from the Division of Research andDemonstration Grants, Social and Rehabilitation ServiceDepartment of Health, Education and Welfare, Washington,D.C. 20201.

Significant Findings For Rehabilitation Workers

1. Malposture is a common finding in the blind and contributessignificantly to difficulty in orientation and mobility.

2. The problems of posture in the blind are peculiar to thestate of blindness (particularly in the congenitally blind),and an understanding of their determinants is essential forproper diagnosis and treatment.

3. The specialties of orthopaedics, physical therapy, andspecialized physical education can play a significant rolein the diagnosis and treatment of malposture in the blind.These specialties should be utilized more fully in thetotal rehabilitation of the blind.

4, Therapeutic techniques, such as specialized exercises,training splints, balance training, mannequin brailling toiiprove body image, physiatric techniques to enhance ver-tical concept, and mobility training utilizing basic pos-tural reflex patterns are effective in the treatment ofmalposture in the blind.

5. Postural evaluation is an important part of the totaldiagnosis of blindness, and postural training is oftennecessary to reach full travel (and rehabilitation) po-tential.

Acknowledgments

The Director and Administrator of this project are par-ticularly appreciative of the cooperation given them by thefollowing,

Alfred Slicer, Director, Division of VocationalRehabilitation, State of Illinois.

Edward T. Weaver, Director of Department of Chil-dren and Family Services, State of Illinois.

William H. Ireland, Director of Planning, Office ofPlanning and Community Development, repartment ofChildren and Family Services, State of Illinois.

Lee A. Iverson, Director, Division of Education andRehabilitation Services, Department of Children andFamily Services, State of Illinois.

Charles Adams, Chief of Rehabilitation Services,Department of Children and Family Services,State of Illinois.

In addition, recognition must be accorded personnel in alldepartments of the Illinois Visually Handicapped Institute,Chicago, Illinoira. Their help contributed significantly tothis study.

We thank the International Journal for the Education of theBlind, the Journal of the American Physical Therapy Associa-tion, the New Outlook for the Blind and the American Associa-tion for the Blind for permission to use material publishedearlier.

Further appreciation is extended the Department of Health,Education,and Welfare, Sooial and Rehabilitation Service,Washington, D.C. for their patience and assistance in thecompletion of the project.

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Abstract

This study deals with the problem of malposture in the blindand its affect on orientation and travel skills.

A group of 45 students were enrolled in a standard three-month mobility training program. Each student. suffered apostural problem, some compounded by severe orthopaedicand/or neurological deficit. All subjects were given com-plete orthopaedic and neurological examinations as well asa battery of speclal psychometric tests. Postural problemswere diagnosed and treated by a variety of therapeutic tech-niques, some newly described, including specialized exer-cise, splintage, postural physical education programs, etc.Improvement evaluation (by motion picture photography) wasmade before, during and after the three month program. Thehypothesis tested was that improvement in posture contrib-uted to improvement in mobility. The final results indicatedsuch a correlation to exist.

The implication of this work is that postural training playsan important role in the development of mobility skills andthus in the total rehabilitation of the blind.

Table of Contents

Professional StaffForewordPrefacePurpose of ResearchBackground StatementStatement of the Problem

Review of Literature,

General ConsiderationsBans of Postural ControlPostural ReflexesSpatial PerceptionBody Image

Biomechanios of Gait

Description of Research,

IntroductionDefinitionsDelimitations

Methodology,

DesignSample

Data Collection Procedures and Instruments:

Diagnostic PhaseDiagnostic PhaseDiagnostic PhaseDiagnostic PhaseTreatment Phase -Treatment Phase -

- Mobility- Medical- Psychological- MiscellaneousMobilityMedical

Photography Recording Techniques

Physical Therapy Techniques,

EvaluationTreatment

Special Clinical Report

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9111619

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272829303031

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Table of Contents cont'd.Page

Results:

General Remarks 44Scoring Key for Data Charts 44

Discussion:

Chart 1 - Improvement in Postural Therapycorrelated with Final ImprovementScore 45

Chart 2 - Improvement in Mobility correlatedwith Final Improvement Score 46

Chart 3 - Psychometric Testing of Gross FormRecognition correlated with FinalImprovement Score 46

Chart 4 - Psychometric Testing of ManualTranscription of Arcs of a Circlecorrelated with Final ImprovementScore 46

Chart 5 - Psychometric Test of Manual ParallelDiscrimination correlated withFinal Improvement Score 47

Chart 6 - Improvement in Postural Therapycorrelated with Improvement inMobility 47

Implication of Results 48

Diagnostic Treatment Matrix 50

Charts,

1. Improvement in Posture Therapy 592. Improvement in Mobility 603. Psych. Test I 614. Psych. Test II 625. Psych. Test III 636. Improvement in Posture Therapy and Improvement

in hobility 64

Summary

References

Appendices

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Professional Staff

Thomas J. Murphy, Project Director and Superintendent,.Illinois Visually Handicapped Institute

Irwin M. Siegel, M.D., Chief Investigator

Lawrence Ginensky, Director of Clinical Services, IllinoisVisually Handicapped Institute

Alice Drell, Education Director, Illinois VisuallyHandicapped Institute

Judith Pillar, Staff Psychologist

Al Manaster, Staff Psychologist

Michele Atella, Staff Psychologist

Jeannette Seaberry, Staff Psychologist

Lois Keim, Mobility Specialist

Sue Stealey, Mobility Specialist

Paul Taviani, Mobility Specialist

Martha Cole, Mobility Specialist

Michael Thuis, Nobility Specialist

Myrna Turner, R.P.T., Physical Therapist.

David Adams, Special Education (Physical Education)

Lester Thiede, Special Education (Physical Education)

Rosetta Rietz, Special Education (Montessori Techniques)

Sharon Kosturik, H.N.

Joan Haggerty, R.N.

Kathryn A. Dozen, Research Assistant

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Foreword

The special problems of posture with Which those without sightmust cope, particularly as they affect orientation and travel,are apparent to all who train the blind. As an orthopaedicsurgeon, I have treated many posture problems, but always insighted patients. When I first became interested in malpos-ture in the blind, I blindfolded myself and entered a worldwhere posture, balance and mobility were not governed by sight."If not by sight, then by what?" I asked. This single ques-tion inspired the project I am about to describe.

A review of the literature revealed that although practitionersnad for years been aware of the postural problems in the blind,little had been done to investigate this matter. A survey bymail of leading agencies for the blind in this country andabroad produced no information of ongoing studies in this area,but each facility contacted expressed an encouraging interestin the thrust of this research. During the planning phase forthis study, major facilities for the treatment of the blindwere visited in this country. The lack of diagnostic andtherapeutic techniques to deal with malposture in the blind wasapparent. Additionally, the directors of all centers visitedwere hopeful of any help available in dealing with these prob-lems.

It is our desire that this project will prove a fit beginningfor continued research in this field. It is apparent that theskill of a variety of ancillary specialties can be well appliedto the problems of posture in the blind, and, hopefU117, thisand similar work will inspire and intensify cross disciplinaryexchanges of information and methods and further investigationof this vital problem.

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Preface

Expression of Posture in the Blind

It is not empty rhetoric to refer to posture as an expres-sion. Posturing is the principle method of communicationamong pre-human anthropoids and in modern man plays an impor-tant role in the expression of attitude.

By "posture" I mean a process, not a condition. A process ofstabilization in motion as well as at rest. In this way anindividual experiences the environment and conditions hisresponse to it - his direct response, his expression, if youwill.

An infant's posture is determined mainly by reflex mechanism.The development of binocular vision in the growing animal sub-serves the need for spatial orientation and gradually sup-plants the responses of postural reflex activity in orientingthe organism and maintaining balance. Although this complexactivity is disengaged in the sighted adult, it is nonethe-less present and active at times of special need. Generallyspeaking, upper extremity postural reflexes are lost at anearly age while those in the legs are retained into adulthood,

Human gait represents a closed kinetic chain in which there isan alternating loss and recovery of equilibrium. During therhythmic play between swing and support in the lower extrem-ities, accompanied by a shift in the center of gravity andresulting in forward propulsion and elevation of the body,postural reflexes are called into action. The ultimate re-finement of these operations is the achievement of movementwhich is almost fluid and accomplished with the least possibleexpenditure of energy in a state of near relaxation. To real-ize this cosmetically and functionally desirable condition, anindividual requires three things: 1) adequate spatial orienta-tion including a valid concept of the vertical ;2) well con-ditioned postural reflex mechanisms; and 3) an appropriate andaccurate body awareness,against which stance and motion can bepatterned. The blind, indeed, are often wanting in these requi-sites. If any sighted individual doubts this, let him attempttravel while blindfolded.

The experience and expression of posture in the blind is pre-dominantly regulated by those reflex mechanisms which visionsupplants in the sighted. These include the tonic neck reflex,as well as positive supporting responses and other statatonioreactions. In addition, and this is particularly true in thecongenitally blind, there is evidence to strongly suggest thatan accurate concept of verticality, necessary for proper ori-entation, is lacking. Lastly, that body awareness and image,against which a blind person models his posture, are frequentlyin error.

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Persistent malposture in the blind may cause discomfort andcreate serious difficulties in orientation and mobility. Anyprogram designed to teach travel to the blind is incompleteunless it considers these problems, and any method for treat-ing postural divergency which does not include techniquesacknowledging the postural reflex, vertical concept and bodyimage needs of the blind pupils is inadequate. Such tech-niques may include specific exercise programs, reflex splinting,and postural reconditioning aimed at improving the individual'sproprioceptive spatial orientation.

Although faulty body mechanics can initiate difficulties insegmental alignment and subsequent postural problems, goodposture is almost always synonymous with adequate kinestheticawareness. It is to tne improvement of this awareness thatposture and mobility training in tne blind should be directed.

Let us make no mistake, a person truly handicapped is one un-able to fully use that with 'Mich he is naturally endowed. Byexploiting effective postural reflex mechanisms, by trainingvertical spatial orientation, and by developing in each stu-dent an appropriate body image, postural illiteracy can beremedied and effectiveness in orientation and mobility en-hanced.

In this way, the expression of posture in the blind need notbe one of tension, fatigue, and distortion. Rather, it willreveal the freedom and dignity that accompany the dynamicsense of the upright wnich effective posture inevitably cre-ates.

Purpose

The purpose of this research was tol

1) Investigate the determinants of posture and posturaldivergency in the blind (including body image, pos-tural reflex ability, postural cognizance, and pro-prioceptive spatial orientation).

2) Study the correlation between malposture and mobilityand orientation problems in the blind.

3) Develop diagnostic and therapeutic techniques forthese problems.

4) Apply the above techniques to the vocational reha-bilitation of a blind population.

Background Statement

A comprehensive definition of posture eludes anyone who con-cerns himself with its nature or its problems. However, itsinvestigation is as old as medicine itself. It is mentionedin the Hippocratic texts. The very word orthopaedics, ascoined by Nicholas Andre in 1741, is derived from the twowords "orthos" (straight) and "paidios" (child). As early as1670, Bernardino Ramazzini considered correct postural train-ing in his classical paper on occupational medicine,and laterin the early 1800's Jacques Mathieu, believing that deformi-ties could be repressed or prevented by the development ofproper muscular balance, incorporated a program of posturaltraining in his orthopaedic sanitarium.

Posture then is not a condition, even though the earliestdefinition of the word (1628) was "to place in position, toset". Neither is it solely an attitude. Goff characterizesit as essentially "made up of meaningful motions of the bodyin relation to its many parts", and suggests that it bestudied not only relative to the postulates of body mechanics,but also in "terms of poise, either in preparation for motionor in actual motion".

Howorth investigated the dynamics of postural movement. Al-though including the fundamental static positions of lying,sitting and standing, it is, he stated, through the dynamicpositions of the body in action that posture becomes most im-portant and moat effective. "Movement is the basis of dynamicposture".

In 1961 McMorris described posture as the end result of theinterrelation of parts of the body in their overall reactionto the pull of gravity. Another more inclusive definition hasbeen proposed by Crowder. "It is essentially a psychosomaticphenomenon controlled by the brain, regulated by spinal re-flexes, and executed by the muscles".

Thus, we come closer to a total conception of the complexevent of posture. It has a psychic as well as a somatic com-ponent, and its functions, mediated through muscles actingupon the body articulations, are under reflex as well as con-scious control.

The solution to any problem consists in reducing it to its ele-ments. In this way we approach the study of malpoature in theblind. Attention was given not only to body mechanics, butalso to the reflex control of both static and dynamic body ten-sions. Also, the psychic influence on spatial concept and po-sitions and its correlation with the other elements of posturalsense were considered. Finally, evaluative and correctivetechniques, using all elements of the postural complex, weredeveloped.

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Thus, it was the purpose of this study to examine the prob-lem of posture in the blind, particularly as it relates toeffective appearance, functional orientation, and efficientmobility. An outline of the determinants of posture, a re-view of the examination and diagnosis of malposture, and anoutline of treatment techniques for postural correction willbe presented.

Statement of the Problem

The research assumption was that the determinants of ade-quate posture and mobility in the blind include an appro-priate body image, adequately functioning postural reflexability, an appropriate perceptual cognizance, including aconcept of verticality and optimal motor perceptual abilitythrough proprioceptive spatial orientation.

Deficit in any of these areas causes postural divergency.Postural divergency adversely affects not only health, butmobility and orientation. The specific cause of such diver-gency can be diagnosed and treated, restoring the individualto a state of optimal postural efficiency and rehabilitation.

Data was collected on each member of the study group as toage, sex, visual status (total or partially sighted, congen-ital or adventitiously blind, etiology of blindness, etc.)past history of problems of malposture, ancillary illness,psychological status, etc.

Each subject was given a battery of psychometric tests todetermine form concepts and their relationship to orientationand mobility activities. Each subject was examined to deter-mine the postural status. Examination included a completeorthopaedic evaluation, as well as a neurological examinationto determine the subject's state of kinesthetic awareness. Theresearch tools outlined below were utilized in this examina-tion. Each subject was programmed in consultation with the re-search staff (project director, physical therapist, peripato-logist, psychologist, and other ancillary personnelpas indi-cated). Treatment utilized weights, braces, exercises andequipment outlined below. 'Comparisons were drawn between thestudent's proprioceptive spatial orientation, postural reflex,body image, perceptual cognizance, and the student's abilityto perform mobility tasks requiring adequate posture upon admis-sion to the Institute, during training, and upon conclusion oftraining. Permanent records of these findings were kept throughphotographic techniques. Changes were verified by a panel oforientation and mobility experts. They rated the students asunimproved, improved, markedly improved. These three groupswere studied for characteristics which might be helpful in pre-dicating success or failure of a particular student and theresults of the Institute program.

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Review of Literature

If good posture results in balanced coordination withoutstrain, then good posture is a goal to be sought, particu-larly by the blind who require the freedom of effectivemobility.

It has been said that "posture has a direct relation to thecomfort, the mechanical efficiency and the physiologic func-tioning of the individual" and "faulty posture can directlyor indirectly impair proper circulation and body metabolism".Muscular efficiency is decreased and abnormal tensions andstrains are placed on the joints and their allied structures.

Pain secondary to malpostural muscle tension, particularly inthe back and neck, is a common complaint in postural strainsyndromes. Muscular and para - articular stress secondary tomaiposition of body parts can aggravate and accelerate a pre-existing arthritic condition. An excellent survey of thosediseases caused or aggravated by poor body alignment has beenwritten by Kuhns. The extent and seriousness of malposture inthe sighted population have been reported by Michele andCrowder. The latter author in his interesting review on pos-ture and body mechanics pointed out that the examination ofyoung men and women entering the British Armed Forces dis-closed that over 75 per cent had a postural error of somekind.

Similar studies with the blind have been few, but as early as1917 Swinerton editorialized on the need for "corrective gym-nastics" in the treatment of some postural defects and habitmotions among the blind. In 1930 the same author reported onthe orthopaedic examination of 180 students at the PerkinsInstitute for the Blind, among whom were found a total of 260structural* or flexible** postural defects.

Boettger, writing on the objectives of physical education inthe blind, outlined an exercise program for postural correc-tion which would help to instill proper habits of thought andfeeling as well as of aotion. Other authors have emphasizedthe need for such training programs in the overall rehabili-tation of the blind. Struad in 1963 reported on the exami-nation of 60 pupils (school for youths with visual defeats inPrague, Czechoslovakia) and found that 77 per cent had pos-tural defects including defective deportment and spinal de-formity,

It has been our observation that postural defect inhibits

*noncorrectible through exercise**secondary to faulty postural habits and correctible through

exercise.

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efficient gait and use of the cane. This situation is oftenoverlooked in the travel training of the blind, much to thedetriment of effective mobility.

Hoover, in discussing orientation and travel techniques forthe blind, noted the need for better methods of travel train-ins.. The development of such methods should include examina-tion of the determinants of posture, the influence of poorposture on movement, and the integration of postural correc-tion into the mobility training program.

Posture - Some General Considerations

Rehabilitation is the restoration of the disabled to thefullest functional attainment to which he is capable. In theblind this concept is of particular importance because suchindividuals have to live and compete in the world at largewhere it is often necessary that they appear and functions atleast as well as, if not better than, their sighted peers.

One of the keystones in the bridge from blind disability toability despite blindness is good posture. As almost poetic-cally stated by Howorth,

"Good dynamic posture frees the inclividual fromtension and gives the body a feeling of lightness,moving through space rather than being earthbound.The body then becomes the instrument of the indi-vidual rather than the anchor dragging at the day'sactivities. The tendency to fatigue is reduced andthere is more energy left for other things. Ac-cidents are less common and usually less seriouswith good dynamic posture. The principles of gooddynamic posture, precision, smoothness, power,balance, good timing, rhythm, coordination may beused not only for the physical body in action butalso as an approach to life itself."

Lowenfeld pointed out in his article on the effects of blind-ness on the cognitive function of children, that restrictionin mobility potential can be regarded as the most severesingle effect of blindness and that educational methods fortraining of the blind in the area of mobility should aim atdeveloping the highest degree of independence by cultivatingeach individual's full mobility potential. This investigatorfurther observed that the blind are frequently disturbed by afear of being observed by others,. so that they feel they mustcontrol their movements and behavior, thus producing a stateof self-conscious tension.

We have noted that the development of postural poise, or whatmight be called dynamic cosmesis (the sense of creating a goodappearance), can do much to relieve this tension. The response

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that one evokes from the environment helps construct the imagethat one has of oneself. This constant feedback in great partdetermines one's attitude and responses to the world. Inshort, it is important that the blind individual create animage of relaxed equilibrium and mobile independence.

Although any postural problem may be found in the blind, thosedefects most frequently seen include pelvic tilt, increasedlumbar lordosis (swayback), thoracic kyphosis (round back),andflat chest. In association with these deformities, we fre-quently note abdominal protrusion and knee flexion with ad-vancement of the head, neck, and shoulders. Also seen arewide-based gait with out-toeing (duck waddling gait).

Habitually poor posture, such as described above, overstretchescertain muscles and ligaments while allowing others to relax.The stronger shorter ones contract, perpetuating the ill ef-fects of the original malposition. Aside from the symptoms andspecific effects of this faulty deportment, including vis-ceroptosis, decreased respiratory function, pes planus (flat'feet), back- and neck-ache, leg and foot pain, and a generalemotional attitude of depression, such a stance and the gait itproduces interdicts the sureness of carriage necessary for goodmobility and travel.

Good postural balance is secured by maintaining the center ofgravity over the feet. In the sighted, occular coordinationplays a major role in obtaining this. In the nonsighted, thesemicircular canals and the proprioceptive sense of the mus-cles and joints subserve this function entirely. With thebody moving forward, the center of gravity advances in front ofthe feet and provides forward momentum. In this sequence thehead leads and the body follows.

The Basis of Postural Control

Posture is not a state, it is a process. It is determined byimpulses received in the spinal cord from muscle, from tendon,and from other proprioceptive structures. It is therefore ina state of continuous adjustment. Barlow suggested the term"postural homeostasis" be used to cover this idea, "in orderto get away from the usual concept which for most people im-plies some fixed position which can either be right or wrong."

Other important physiological findings relevant to an under-standing of posture control have been enumerated by Burt andTurner. In their article on faulty posture they refer toCrowder who demonstrated differences in blood flow to musclesduring dynamic activity as well as static activity when bloodsupply does not equal blood demand.

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These authors also mention the work of Cathcart who statedthat when the static element in muscular effort becomes domi-nant,"static expenditure is parasitic on dynamic work." Themore static the work becomes, the greater is the fall in ef-ficiency.

Based on these considerations, certain principles of treat-ment were postulated by Burt and Turner: 1) Because less in-formation is received by the central nervous system when mus-cles are contracted than when relaxed, and because the bloodsupply of muscles is decreased during static contraction,thecorrection of faulty posture by muscular relaxation techniquesis physi,ogically sound. 2) Because the higher centers actingon the muscle spindles play a considerable role in forming thepostural habitus, an important part of correctional techniquemust be the substitution of a good for a poor postural bodyimage.

Sherrington in "The Integrative Action of the Nervous System"distinglished and investigated the reflex system which "main-tains that steady tonic response which supplies the musculartension necessary to attitude." Brain, in discussing thesematters, referred to the classic work of Magnus and DeKleijnwith tonic neck and labyrinthine reflexes in supportngSherrington's idea that the head plays a significant part inregulating bodily posture.

Of those physiological mechanisms subserving the maintenanceof postural tonus, the tonic activity of muscle is, from thestandpoint of postural correction, the most significant. Thisactivity is controlled by a spinal reflex, known as the stretchreflex, which involves a servo-mechanism: that is, one in whichthe control system is to some degree regulated by data feed-back from the system controlled. Electromyographic studieshave revealed that in tension states leading to increased mus-cle tonus, prolonged muscle contraction decreases "feedback tlthe central nervous system." Thus, information about posi-tion sense is not supplied to the subject and he is unaware ofhis abnormal posture. The importance of this observation inthe postural care of individuals lacking sight and relyingalmost solely on propriocepti, , postural information should beapparent.

Barlow, in elaborating his approach to postural re-education,emphasized the association of faulty posture with maldis-tributed tension. He, as Sherrington, Magnus and DeKleijn,believed that "the primary defect in postural disorders isusually in the region of the head and neck". He spoke ofbodily disposition and behavior (rather than structure) as de-termining the mechanics of the body. By behavior he referredto all the habitual motor responses with which the body re-acts to the outside world and by means of which individuals

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adapt themselves to stress. His system of postural educationinvolves the reconditioning of correct tensional balancethrough demonstrated instructions.

As has been noted, static holdings serve only to fatigue mus-cle and decrease the afferent flow of propriooeptive in-formation. If remedial exercises are to he used in a programof posture retraining, their final object should be the de-velopment of new postural reflexes. This can usually beachieved by repetitive postural movements which begin and endin a position of correct posture and by habitial adoption ofcorrect posture with conscious correction each time it flags.

Finally, every enlightened system of posture training shouldtake account of the concept of body image (postural awareness).As noted by Crowder (loc.cit.), "the body image is a compo-nent of the personality and conversely the personality is re-flected in thebody posture, just as it is in the individual'sspeech or dress." Barlow stated that "the cause of the prob-lem of postural control is the subject's postural awareness,and, at a different level, the postural model or body schemawhich the subject uses is a standard against which he detectshis postural error. One soon finds that postural awarenessoccupies the key position in determining a person's idea ofhimself and that as this awareness alters, profound altera-tions may take place in habits of thought."

It is our opinion that in the absence of sight, proprio-ceptive postural reflexes, such as the tonic neck reflex,aremajor determinants of postural attitude. It is also our im-pression that the concept of verticality and an individual'sbody image, particularly as they relate to spatial orienta-tion, are grossly distorted in the blind individual. Suchfactors profoundly affect posture and mobility in the blindand must be taken into account in any sensible program ofpostural training for the blind.

Postural Reflexes

To discuss posture without examining postural reflex would belike discussing art without mentioning color, or music with-out considering tone.

Experimenters and clinicians alike have long been aware of theimportance of postural reflex in establishing body set bothst rest and in motion. The fundamental work of Sherringtonand Magnus and DeKleijn, as well as others, laid the experi-mental groundwork for clinical study of these phenomena.

The postural reflexes are automatic reactions maintaining bodyorientation. Postural adjustments are constantly under thecontrol of sensory organs located within the joints of theneck and the labyrinth of the inner ear. Coordination of

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axial and appendicular posture is primarily determined byhead position. According to Magnus, position of the headexercises the prime influence on body attitude. Head turninginitiates tonic neck reflexes which are integrated in the up-per cervical segments of the spinal cord. Rotation of theneck produces extension of the limb on the side toward whichthe jaw is rotated and flexion of the contralateral limb.Dorsiflexion of the neck produces forelimb extension andhindlimb flexion, whereas volar flexion produces forelimbflexion and hindlimb extension. The muscle tone excited bythese reflexes ha: been shown to produce very little fatigue,and therefore appropriate postural attitudes can be maintainedwith minimal energy expenditure. As Sherrington noted, "onegreat function of the tonic neck reflexes is to maintain ha-bitual attitudes and postures. They form, therefore, anervous background of active equilibrium."

In addition, secondary tonic reflexes contribute to the co-ordination of muscle tone and attitude throughout the body,thus maintaining characteristic body orientation. Stretchreflexes, positive supporting reactions, righting reflexesand other statotonic reflexes, produced by movement of thehead or limbs (linear acceleration, angular acceleration, etc.)integrate to produce the total complex of postural tone.

As early as 1938, Gesell described the tonic neck reflex inthe normal human infant. He explained this phenomenon on theteleological basis that "man does not face the world on afrontal plane of symmetry, but at an angle and he makes hisescape obliquely. This orientation is prefigured in the tonicneck reflex attitude of infancy... It subserves adaptations tothe environment, prior to birth, as well as later."

Bieber and Fulton further related the grasp reflex to thetonic neck and labyrinthine reflexes. Kesareva investigatedthe phenomena of tonic neck reflexes in normal adults usingmyotonographic and tonometric methods. It was his opinionthat the main significance of these reflexes lies in theircontribution to the preservation of body balance.

Two of the most searching studies of the role of postural re-flex activity in normal human beings are those of Fukuda andHellebrandt et al. The former, reporting in the otolaryngo-logical literature, illustrated the importance of these reflexphenomena in the kinetics of everyday activity and athletics.In his excellent monograph which demonstrates and documentsthe fact that the tonic neck and labyrinthine reflexes regu-late head and limb movement, it is shown that the basic dy-namic posture position described by Howarth (vide supra) isalso the most efficient dynamic postural position from thepoint of view of postural reflex. Reference is also made tothe sport of fencing as an excellent postural reflex condi-tioner,and this will be discussed later in this report.

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Hellebrandt and associates reviewed the literature which re-vealed "an increasing appreciation of the contribution of neckand labyrinthine proprioceptive mechanisms to motor coordina-tion in the intact organism." In their laboratory they con-firmed the presence of tonic neck reflexes in normal humanadult subjects. Another study which has shown results con-cordant with those mentioned above is that of Wells.

The utilization of head and neck posture to facilitate work-output has been reported by Latimer, and Walshe believes thatreflexes regulating head posture might arise in the limbsthemselves. In 1956 Hellebrandt et al demonstrated the fa-cilitation of purposive stress movements by reflex head andneck positioning, concluding that "... reflexes arising in thelimbs themselves during heavy resistance exercise in man re-gulate the posture of the head and this in turn expedites per-formance..."

The literature is replete with papers illustrating the rolethat reflex postural phenomena play in pathological states ofthe central nervous system. A study of these reflexes in tha-lamic man was made by O'Neill and illustrated that, indeed, asMagnus and DeKleijn demonstrated in their laboratory prepara-tions, tonic cervical reflexes govern head position relativeto the body while labyrinthine reflexes govern spatial posi-tion of the head in relation to gravity.

Further clinical observations reported by Simons in the Ger-man literature, beginning in 1920, have been abstracted andtranslated by Brunnstrom. The influence of tonic neck re-flexes on the activity of trunk muscles in patients with res-piratory illness has been noted by Moltke and Skouby. Asmentioned before, Walshe postulated synergic postural fixa-tion from limb activity, and in a treatise on postural re-flexes in hemiplegia described tonic reflexes arising in thelimbs and acting on the limbs, as well as tonic reflexesarising in the neck and acting on the limbs. Yamshon and hisassociates have examined the therapeutic implications of thetonic reflex in the hemiplegia. Finally, such investigatorsas the Bobaths have studied and used postural reflex activitydirectly in the treatment of spastic paralysis.

In discussing 4-le role of the basal ganglia in locomotion,Martin reported several phenomena which relate much of this tothe problem of posture and mobility in the blind. Investiga-ting the physiological mechanisms concerned in the posturaladjustments of locomotion, he described the normal side toside movement which occurs upon weight transference from onefoot to the other and back again, the swaying of the upper bodycounterpoising the swinging leg, and the forward motion of thecenter of gravity which provides propulsion. He noted thatordinary visual stimuli are not adequate to excite the postural

14

reactions of walking* and that the effects of body rockingmay be due partly to reinforcement of proprioceptive stimulifrom the joints. thus strengthening proprioceptive reflexesfrom the extremities. He asserted further that visual re-flexes have more effect on the lateral postural ajustments ofwalking than on anterior-posterior control.

Other reports have touched upon these matters. Critchleymakes reference to proprioceptive stimuli in stating that"blind people are perhaps more mobile and restless thansighted ones... these movements may be so exaggerated as toconstitute curious stereotype tic-like mannerisms - - blind-isms as they are called." Indeed, Muller, observing 340blinded children, enumerated a variety of rhythmic motions in34 per cent. Our observations have been that such mannerismsmay well represent an effort on the part of the blind indi-vidual to compensate for loss of visual orientation by anoverstimulation of labyrinthine and proprioceptive joint func-tion. Certainly, rocking and swaying are seen frequentlyenough among the blind to represent more than a casual occur-rence.

AB Halpern has shown, "normal statokinetio function is theresult of steady, correct perception of the horizontality ofthe ground planes and of the vertical planes passing symmetri-cally through the two halves of the body." Lacking opticfunction for this perception, the role of neck proprioceptivemechanisms in body orientation and motor coordination becomesparamount. Bodily attitudes change with change of head po-sition, the proximal end of the body acting as a leader forits distal segment.

Wapner and Werner have determined that information relayedfrom neck proprioceptors has an important influence on the or-ganism's ability to orient. These investigators found that avertical rod appeared always to rotate to the opposite sidefrom that on which an electrical stimulation of the neck wasinduced. Cohen ablated neck proprioceptors in monkeys andcreated severe deficits in orientation ability and motor ac-tivity. On the other hand, surgical detachment of extraooularmusculature in his animals did not cause any observable dis-orientation or incoordination. Jones and his associates, inan outstanding series of studies, developed a method of uti-lising interrupted light photography to record the effect ofhead posture upon patterns of movement in man,and describedan empirical technique for changing the distribution of postur-al tonus by changing the poise of the head, thus proving thathabitual patterns of movement in posture can be modified bytraining in kinesthetic perception. It has been suggested

*It has been demonstrated elsewhere that propriooeptive im-pulses are not mediated by extraocular muscle without visualloss.

15

that this method reflects the operation of the head and neckreflex elucidated by Magrus and Delileijn.

As has been pointed out, the therapeutic significance ofpostural reflexes has beer successfully exploited by Barlow.In addition, eleetromyographic demonstrations of muscle workoutput facilitation have indicated that movements at firstevoked only reflexly, can be brought under willful controlthrough systematic training. The work of Wapner and Wernerrevealed that when the head or body is tilted to the right,the apparent position of the vertical is objectively tiltedto the left and vice versa. Further, it has been oonfirmedthat with changes in postural status,there are not onlychanges in the organization of space, but also in the distri-bution of sensitivity. McFarland, Werner and Wapner haveshown that head and body tilt left increases right-sidedsensitivity and shifts the straight ahead to the right andvice versa. This ideation of tactile and kinesthetic (pro-prioceptive) sensibilities is elaborated by Bender andElizan who demonstrated that defects In the perception ofthe direction of drawn lines are always associated with enimpairment of sensory function mediated by the "proprio-ceptive" system. It is thus plausible to postulate a re-lationship between sensitivity distribution and organiza-tion of space.

To summarize, lackingnonsighted individualceptive mechanisms toThese mechanisms are,individual is seekingto orient visually.

the means for visual orientation, therelies primarily on reflex propriomaintain posture and to locomote.of necessity, exaggerated because theto compensate for loss of the ability

Primary among the reflex mechanisms creating this backgroundof postural tone that makes all orderly movement possible arethe tonic neck reflexes described in detail above. The headleads and the body follows.

Misconceptions as to the true vertical as well as the body'sposition in space can and frequently do occur because ofadventitious head and body tilt. In an effort to orient ex-clusively through the use of proprioceptive mechanisms,swaying, rocking, tilting and other objective signs of mal-posture occur. Indeed, the very act of extending the canebearing arm initiates a widespread synergic postural fixa-tion, the arm in this case acting as a handle which turns thehead and thus the body, there being a reciprocal reflex re-lationship between limb, head and body posture.

As Jones and O'Connell have stated, "posture is a manifesta-tion of the changing relationship among the parts of an inte-grated whole." Therefore, to deal intelligently with anyproblems of postural disorder, but particularly those of the

16

blind, one must evaluate malposture in terms of what posturalreflexes are in force and what reflex maneuvers can be usedto modify postural set.

Snat'ial PerclEgjla

To organize reflex activity into effective posture, the or-ganism must employ an accurate idea of true vertical. Numer-ous investigations into various determinants of such a con-cept have been conducted. The research of Wapner, Werner,and associates has led them to postulate a sensory-tonicfield theory of perception. Witkin has gone a step further,correlating certain aspects of perception with a theory ofpersonality structure.

Werner posits structuring of a perceptual field not alone asa sensory, but also as a "toniefield. He quotes studieswhich demonstrate the influence of sensory stimulation uponthe distribution of tonus, as well as experiments indicatingthat tonus has formative power in structuring a perceptualfield within the organism. Thus. space as perceived by theindividual is organized "...not as a purely sensory area,but as a sensory-tonic field."

In an effort to elucidate the effects of extraneous stimula-tion on object perception, Wapner, Werner,and associatesfound that "...verticality is a spatial property of anobject which can be experienced by kinesthetic as well as byvisual clues." These investigators found that to blindfoldedsubjects the position of a rod kinesthetically perceived asvertical was objectively tilted to the left when either thehead or body was tilted to the right , or the body was ac-celerated in a clockwise direction or decelerated from con-stant counter-clockwise rotation. For opposite test con-ditions, the respective displacements were in the oppositedirection. These effects had been previously described bythe authors utilizing visual perception of verticality.Werner et al further demonstrated that "... under identicalangles of body tilt, the position of a rod indicating ap-parent verticality is displaced to a greater degree from theperpendicular when the body is unsupported than when it issupported...and angle displacement of the apparent verticalincreases with an increase of body tilt." Thus, the sensory-tonic field of perception defines posture as a dynamic stateinvolving the continuous patterning of reflex processes,theefficacy of posture residing in these processes rather thanin body position per se.

Lacking a visual field, one perceives the direction ofgravity through the continuous pattern of adjustment whichthe body is making to its pull. Witkin and Asch's ex-cellent review on this subject describes the phenomenon of

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perception of displacement of the upright to the opposite di-rection of body displacement with large body tilt (Aubert orA-phenomenon) and perception of displacement of the uprighttoward the body with small body tilt (E-phenomenon as named

These experiments are significant in that they emphasize theimportance of vision in perception. In the absence of sight,a host of factors including illusions of size, depth anddistance, as well as the postural basis for judgment attemptto substitute for the visual frame of reference. Such esti-mates of velticality were found to be most accurate when thebody was upright, but significant error appeared as soon asthe body, or even the head alone, was tilted. Minor changessuch as these had very disturbing effects on a subject'sability to orient to the vertical when deprived of visualclues. This illustrates the limited usefulness of posturaldeterminants alone in providing the organism with a validconcept of verticality. Witkin postulated that errors inperception of the vertical lie in the individual's "par-ticular mode of perceiving this situation, or in the sup-pression of certain experiences under conditions of sensoryconflict". A provocative finding in one study was thatwomen as a group make greater errors in perceiving the ver-tical than do men.

The aforementioned work has been complemented by experimentaldata from a number of laboratories. Significant decrease inthe precision of judgment of postural vertical from lateraltilt positions was noted with modification of nonlabyrinthineproprioceptive cues by Mann and associates. In studying per-ceived location of objects and one's body under erect and tiltsituations, using both visual and tactual-kinesthetic testing,McFarland, Wapner and Werner found that, in general, the posi-tion at which the body appeared to be was rotated beyond thephysical body position in the direction of body tilt. whereasthe apparent vertical was rotated beyond the physical verticalopposite the direction of body tilt. Unsupported body tiltincreased the change for apparent vertical and decreased thechange for apparent body position.

It is of interest to note that in reviewing the problem ofcontralateral deflection of the vertical, Sandctrbm remarkedthat "deviations from the true upright with head tilted to theleft are less than with head tilted to the right." Sandstr6m,incidentally, offers an excellent summary of the Aubert andE-phenomenon to which previous reference has been made.

Fleishman, experimenting on the "perception of body positionin the absence of visual cues", also concluded that greaterprecision of adjustment to the upright position results whenthe direction of displacement of the body is to the left ratherthan the right. He found that precision of adjustment was

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increased when head position was fixed under experimentalconditions of body tilt. Smith through a series of ingen-ious experiments with displaced vision demonstrated that per-ception of the upright involved visual, cutaneous and gra-vitational-postural effects in "defining a frame of referencefor orienting the body in space".

In simmArizing the recent research on nonveridical percep-tion of verticality, Curran and Lane asked for objectifica-tion and clarification of the roles that various conditionsplay in contributing to erroneous estimatJs of the upright.They noted that "minimal visual cues had a dramatic effect inreducing nonveridical perception of the vertical", and be-lieve that inferences drawn from the sensory-tonic fieldtheory of perception which suggest that the degree of mus-cular involvement plays an important role in determiningjudgments of body position must remain tentative. Curran andLane suggested that the "use of multi-dimensional experimentswith uni-dimensional variables, sampled at several levels andmeasured on ratio scales, facilitates the analysis of inter-action effects in the perception of the upright."

Although we move in only three dimensions, we live in four,and the element of time must be taken into account to completeour consideration of vertical perception. In commenting on"temporal factors in the perception of verticality", Cohen andTepas found, as did Mann and Passey, that prolonged exposureto conditions of postural tilt increased errors and judgmentsof verticality. Practice in the perception of postural ver-tical, however, resulted in a significant reduction of errorin such judgments. In a series of experiments by Solleythere was improvement in accuracy of perception with practice.Solley also noted (contrary to the work of Sandstrom andFleishman) that left head tilt produced more error than righthead tilt and postulated that this was due to the fact thatthe muscles on the right side of the body are stronger thanthose on the left or because of "long enduring habits ofturning in one direction more often than the other".

This important evidence, namely, that with repeated testing,subjects show a significant reduction of error in perceptionof the vertical and that practice serves to bring about im-proved performance in such judgment, as demonstrated bySolley and affirmed by Pearson and Hauty, is important be-cause it indicates the possibility of training perception ofpostural verticality. If such perception can be a functionof learning, it is feasible that with proper techniques, in-struction can be utilized in developing vertical perception ina nonsighted subject.

In sum then, although perception of the vertical is a multi-dimensional affair, and its final elucidation clearly re-quires a broad program of research, body position and support,

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visual, proprioceptive, labyrinthine, and tactual cues allcontribute to false judgments of the upright.

Another variable,contributing to this perceptual estimate isequally as important, though somewhat less accessible for in-vestigation. This variable is non-reflex and non-somatotonic.It is psychological. It represents the psychic influenceupon the somatic response.

Body Image

According to Gesell, the organism has the innate tendency to-ward "the organization of postural tension, attitudes, andmovements." This organization structures the basis for me,tility. It has been proposed that the individual's per-ceptual experience conditions the ability to be motile, per-ception of body position thus bearing a direct relationshipto motor tasks and skills and appropriate body orientationdepending upon accurate spatial localization of the body aswell as environmental objects. That physical asymmetry maylead to disorientation has been postulated by Lund. This in-vestigator correlated structural asymmetry with the tendencyto veer in subjects who visual sense was excluded. Thework of Wight and associates has confirmed the idea advancedby Wapner, Werner, and Morant of a "central, common field ofinteraction between sensory and motor functioning."

An understanding of the role of the individual's psychic per-ception of his body in space is important for a completeknowledge of the basis for mobility and has, as we shall see,practical implications in the understanding and treatment ofposture and mobility problems in the blind.

Bennett quoted Scott's definition of body schema as "thatconscious or unconscious integration of sensations, per-ceptions, conceptions, affects, memories or images of thebody from the surface to its depths and from its surfaces tothe limits of space and time". In this same review the con-cept of Head and Holmes of a "postural model of the body",which is plastic and modified by every new posture and move-ment representing "the fundamental standard against which allpostural changes are measured", is also presented.

That the postural image of his body which an individual car-ries influences his perception of the upright, has been sug-gested by many of the investigations summarized earlier inthis study. Although knowledge in this area is still limitedand all aspects of the problem have not been fully explored,it would appear that we owe to our psychic body image the"power of projecting our recognition of posture, movement,and locality beyond the limits of our own bodies".

Whether this conceptualization (body image or body schema) is

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In isomorphic relationship to the level of motor skill is notimportant. The essential matter is that such a variableexists and exerts an influence on postural status.

An analysis of space perception in congenitally blind andsighted individuals by Hunter has indicated that the blindlack the ability to utilize various types of stimuli, to thedegree accomplished by the sighted. Epstein, examining therelationship of certain aspects of body image to the per-ception of the upright, postulated that "the degree to whichone conceives of his body structure as differentiated, inte-grated, and free from distortions tends to increase with theability to rely on bodily sensations in determining one'sorientation to the upright: The idea that "body image" notonly defines the individual's concept of his body, but alsoinfluences his perception of it, has been reviewed and ex-tended by Fisher.

The physical problems of blindness cannot aloIJ account forall manifestations of this disability. It has been observedthat with sighted children emotional disturbances betraythemselves in postural difficulties. Burlingham, in re-porting on the development of the blind, notes that the samemay be true for blind.children, "beyond the awkwardness whichis caused by blindness". In speaking of blindisms, thisauthor states, "it is difficult to say how far these rhythmicactivities merely substitute for the more normal muscularactivities and discharge of aggression which the blind chil-dren lack, and how far they have the full value of auto-erotic manifestations."

In considering the psychological problems of the congenitallyblind child, Cole and Taboroff suggest that much of the dif-ficulty these children have is due to their difficulty inimagining "a good external reality, a knowledge of self versusnon-self."

The reduction of his repertoire of responses can lead to adistortion of body concept and consequently a disturbance ofperceptual orientation in the blinded individual. This hasbeen noted to be more severe in the congenitally blind thanin those adventitiously blinded. Such deficits of spatialperception and orientation in the blind have been documentedby a number of studies.

Studying the problem of body image, Kitamura reported thatblind persons overestimated body height. The conditioning ofperception of the upright by set (such as uncertainty) hasbeen examined by Gross,and he observed that when an elementof uncertainty is introduced into the experimental situation,an increase in error of judgment results. Adaptation insuch a situation can occur, however, as the work of Passey

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and Guedry has indicated. These. authors noted that "air-craft pilots report that a gradual departure from 'straightand level' flight with maintenance of inclination for someperiod of time leads to a feeling of 'straight and level' inthe tilted position. When a subsequent return to the 'straightand level' is made, bank and turn in the opposite direction isoften reported".

This potpourri of seemingly unrelated material has practicalimplications in considering the problem of postural trainingin the blind.

The image that the blind person has of his body in space, asit influences his perception and through this impression hismobility, can be conditioned adversely by set and adaptation.Emotional problems may further distort body image and mobilityas the dynamic presentation of this image.

These phenomena are all germane to a complete understanding ofour subject and until fully elucidated, the matter of mal-posture in the blind will not be entirely resolved. Fol-lowing is a report on an attempt to clarify some of thesequestions in an effort to take the initial step toward solu-tion of the problem.

Biomeohanios of Gait

Some understanding of the essential features of normal loco-motion is important to anyone dealing with mobility trainingin the blind because the problems of posture as well as theproblems of mobility in the blind are not altogether differentin kind from the same problems in the sighted. They are oftendifferent, mostly in degree.

Three basic concepts must be understood. 1) The influence ofgravity, including the center of gravity; 2) the problem ofswing and support: and 3) body rotation and the ground force(the frictional force that orients body movement).

Walking is an alternating loss and recovery of support with aseries of displacements of various body parts in severalplanes. The brain, kept informed by the sense organs,directsthe muscles to modulate the effect of gravity on body momen-tum, The center of gravity shifting during locomotion andbody movement in relation to this are important.

The tendency of an individual to fall forward while ambulatingdepends upon several factors, 1) his body weight and 2) thedistance of this weight anterior to his spinal column. How-ever, the spine is not a rigid column, and the various distor-tions resulting from the forward pull of the load of thehuman body constitute the basic conditions inherent in allpostural studies. The application of these simple facts in

2 c)

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the evaluation and treatment of postural difficulties in theblind is obvious. When a student is leaning forward or back-ward, he is not bringing the center of gravity as near as pos-sible to the supporting column of his spine. Leaning makesfor imbalance. Of course, no one walks or stands perfectlystraight, and there is a large margin of normality. The bestchoice is not the same for each individual.

Another biomechanical rule which must be obeyed, else we can-not remain upright, is that the supporting surface must belarge enough to intercept the line of gravity of the body.This is well observed in the leaning tower of Pisa. It ac-counts for some of the wide-based gait seen in children firstlearning to walk, in individuals who are overweight, in preg-nant women, and in anyone walking up a steep incline. Theblind frequently walk with a wide-based gait to increase theireffective supporting surface, so the center of gravity willfall within it, thus facilitating the upright stance.

The lower the center of gravity lies, the greater must be anarc which an unbalancing force must describe. Those of ourstudents who walk with a bent knee gait are trying to lowertheir center of gravity to better maintain balance. However,anyone who stands or walks with flexed joints overloads hispostural musculature. This is one of the reasons we like tohave relaxed adequate postures otherwise, standing andwalking can be enervating.

In an alternating two-legged gait (bipedalism), the abandon-ment of the four legs as a means of support is conditionedupon elevation of the center of gravity, so that it lies overthe supporting area of the two feet. The upper extremitiesshift and balance the trunk over the pelvis, and the armsswing, transferring momentum from one side to the other toprevent undue twisting of the body. If one walks with hisarms straight to the side, the body has to twist to shift itsweight. A tightrope walker uses an extension of his arms totransfer momentum so he does not have to shift at all. Itcould be very dangerous to shift even a little on a tight-rope. Therefore, bipedalism is a combination of rhythmicforward propulsion and elevation of the body. In alternatingbipedalism, only one lower extremity is used at a time, ei-ther as a propelling or restraining force. Propulsion iscarried out by a leg placed on the ground in a backwarddiagonal direction at the moment the propelling leg is pre-pared to leave the ground. Start and stop, heel and toe.

A rapidly growing blind child is awkward in his movements be-cause he has a poor discriminative appreciation of spatial re-lationship and is, therefore, totally oblivious of grosslyfaulty posture. He does not have the vocabulary or the ex-perience. Even minimal conditions of malposture can eventually

2.)

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lead to pain and disability through incongruity in joint sur-faces eventuating in overstretching and weakening of sup-porting ligaments with muscle weakness and fatigue. In ad-dition to this, rather severe difficulties in orientation andmobility result from advanced postural problems. It has, infact, been noted that even such minor movements as noddingthe head and twiddling the fingers modify the performance ofthe lower limbs during locomotion.

Some of the problems commonly seen are as follows:

1) Dorsal round back (kyphosis, often due to a struc-tural problem that cannot be helped by exercise.Sometimes bracing may be necessary.

2) Twisted back (scoliosis), yet another structuralproblem which may occasionally require operativecorrection.

3) Flat feet, often correctable through proper footwear.

These three problems are mentioned because they illustratethe necessity of conducting an adequate orthopaedic examina-tion of each blind student, Frequently, the correction of acommon orthopaedic problem is all that is necessary to im-prove posture in the blind.

However, as noted before, much postural divergency is par-ticular to the fact of blindness. Specialized techniquesare necessary in the treatment of this pathology. Suchmethods aim at teaching the student the feeling of properposture. Reflex splinting is sometimes used, as well asweighting of an extremity to correct the tendency toward im-balance. Apparatus which points the chin, exploiting thetonic neck reflex can be used to advantage, Exercise pro-grams which increase proprioceptive awareness and avoid theenervation of static holdings are of value. The militarystance is something to avoid, We strive for relaxed, func-tional posture. An expanded description of these as well asother techniques will be found elsewhere in this report.

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Description of Research

Introduction

Mobility and orientation training is an essential aspect ofany rehabilitation program for the blind. Effective mobilityis usually a factor in job achievement, and vocational suc-cess is often directly proportional to a blind person's mo-bility and orientation skill. In order to live, work andcompete in the sighted world, it is necessary that the blindindividual travel and function at least as well as, if notbetter, than his sighted peer.

Effective mobility and orientation in the blind are predi-cated upon proper dynamic posture. Such posture is con-ditioned primarily by four influences; a) proprioceptivespatial orientation, b)postural reflex, c) body image, andd) perceptual cognizance. Good posture results in balancedcoordination without strain and, therefore, is a goal to besought, particularly by the blind who require the freedom ofeffective mobility.

The Illinois Visually Handicapped. Institute was interested indetermining and seeking solutions to the problems inherent indeveloping good dynamic postural habits and applying suchknowledge to the mobility training of blind students.

The Illinois Visually Handicapped Institute is a unit of theDivision of Rehabilitative Services in the Illinois Depart-ment of Children and Family Services. It is a rehabilitationcenter for those with less than 10% of normal vision who canbenefit from its program. Since February 1965, the Institutehas been housed in a modern building designed for this specificpurpose at 1151 S. Wood Street, Chicago, Illinois.

Each applicant is given a medical, psychological, social andvocational evaluation and a schedule that meets his specialneeds designed. When entered as a student, a full range ofcourses and services are provided to meet the particular re-habilitation requirements of the individual. The study groupwas selected from these students.

Definitions

Verticality. The upright position. Perpendicular to thehorizontal.

Postural Reflexes. Those reflexes which subserve the sense ofposition in space.

Vertical Concept. Judgment of the body's state of verticality.

Body Image. The mental "picture" one has of one's body inspace.

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Motor Perceptual Ability. Skill in perceiving and performingmotor tasks.

Proprioceptive Spatial Orientation. Body orientation throughthe sense of joint position.

Blind. No light perception in either eye.

Severe Visually Impaired. A visual loss so severe as to be ofno functional use for mobility.

Mobility. The ability of a blind or severely visually impairedindividual to travel independently with the use of a cane.

Delimitations

This study was concerned only with those individuals; a)whodemonstrated a postural defect and difficulty with mobility;b) who received in-residence services from the IllinoisVisually Handicappe_ Institute during the period of this study;c) who were agreeable to participate in the study program; andd) who were under treatment (in the study) for a minimum periodof three months.

The research did not investigate the physiologic basis forpostural reflex mechanisms nor the psychodynamic background ofbody image conceptualization in the blind, except insofar asthese matters directly and empirically affected posture.

Although concerned with the value of proper posture as a com-ponent of orientation, mobility and vocational potential, theresearch did not attempt the study of the role of posture inany specific vocational tasks or situations other than mo-bility.

Although concerned with developing techniques to diagnose andtreat malposture and developing a practical program towardthese ends, the research did not comprise a demonstration pro-ject of such a program.

Methodology

Design

This study utilized a program research approach to identify,diagnose and treat certain blind or severely visually im-paired individuals suffering from a postural defect andhaving difficulty with mobility. The sample was selectedfrom students of the Illinois Visually Handicapped Instituteand demographic data collected on each individual.

A battery of psychometric tests was administered which

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included an intelligence test, a personality test, and spe-cial tests of motor perceptual ability.

A complete orthopaedic examination was given each subjectwith special emphasis on proprioceptive and kinesthetic status.

An examination of both static (sitting and standing) and dy-namic (walking) postural patterns was conducted on each studysubject.

A physiatric examination for diagnosis of conditions af-fecting posture (muscle contracture, ticks, blindisms, de-formity, etc.) was given each subject.

A standard mobility evaluation was performed on each sub-ject. Each student was programmed through motion picturerecording of gait and posture status before, during and afterdiagnosis and treatment.

New treatment techniques applied to the blind and the multiple-handicapped blind student included postural exercise programs,special recreational techniques, and manipulative tactile ap-paratus. This project developed methods for demonstratingcorrect posture and mobility techniques to instructors for theblind, so that the findings might be directly applied in vo-cational rehabilitation programs for the Mind. One methodinvolved rating the degree of improvement by a panel of ex-perts viewing serial movie sequences arranged in random orderto arrive at a rating of 1(a) unimproved; (b) improved, or(c) markedly improved.

The demographic, psychological and postural characteristics ofthese labeled categories was studied to discover relationshipswhich might be of significant predictive value.

Sample

The sample population was composed of students receiving ser-vices from the Illinois Visually Handicapped Institute. Thefollowing criteria for selection of cases was adopted to en-sure a sample population with the required characteristics.

1) Students medically described as having one or morepostural defects.

2) Students demonstrating a skill deficiency in mo-bility.

3) Students willing to undergo a diagnostic study andparticipate in a treatment program.

4) Students :remaining in the project for a minimumperiod of three months.

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These criteria were applied to every applicant to the IllinoisVisually Handicapped Institute during the study period. Thenumber of applications each year average 150, The sample po-pulation consisted of forty-five students.

Each selected student received a diagnostic work-up as de-scribed below, and a medically appropriate treatment programwas prescribed and implemented.

Photographic recording of posture and mobility performancewas done before, during and following treatment. The motionpicture records were reviewed to note the degree of improve-ment in mobility skill.

The students undergoing medical screening, diagnosis, andtreatment for a period of three months comprised the same po-pulation for analysis of data.

Data Collection Procedures and Instruments

General demographic data was collected on all students andreported on Departmental Forms CFS-201, "Face Sheet", andCFS-202,"Application for Admission",Exhibits 1 and 2 respec-tively in appendix.

Diagnostic Phase - Mobility

Orientation skills were tested by asking the student to makecertain degree and compass point turns on command while stand-ing in place. The student's accuracy was noted and recordedin Section III, Parts A,B, and C, of the Mobility EvaluationCheck List, Exhibit, 3, in appendix.

Orientation stability and visual imagery was tested by the in-structor's arm. The student was told which direction he isfacing, that they will walk a pattern, and that the studentwill be asked how many directions they traveled, how manyturns were made, and in which directions, what direction arethey facing on completion of pattern, and can the student re-produce the pattern on paper with a pencil. The student'sresponses were recorded in.Section III, Part D, of the Mo-bility Evaluation Check List, Exhibit 3, in appendix.

Memory, ability to reverse, sense of direction, ability tojudge distance and walk a straight line was tested by givingthe student the following directionss"Walk straight ten feet,turn right and walk five feet, turn left and walk five feet".These directions were repeated as often as necessary beforethe student began. The student's performance was noted andrecorded. The student was then asked to reverse the directionand return to the starting point. The student's performancewas noted and recorded in Section III, Part E, of the Mobi-lity Evaluation Check List, Exhibit 3, in the appendix.

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The student's performance in dealing with stairs was notedand recorded in Section IV of the Mobility Evaluation CheckList, Exhibit 3, in the appendix.

Each student was observed during ambulation along a thirtyfoot track. The student was told to walk straight ahead.The examiner ordered the student to stop, turn around andwalk to starting point. Gait deviations, such as veering,out-toeing, in-toeing, shuffling, head tilting, shoulderleading, or wide-based gait were noted and recorded underSection V of Exhibit 3, in the appendix.

Summary of performance, identifying any defects noted, wasmade and recorded along with the instructor's recommendationsfor a treatment program, if appropriate, under Section VI ofthe Mobility Evaluation Check List, Exhibit 3, in the ap-pendix.

A letter grading (see Exhibit 4, in the appendix), based onthe above noted evaluation was assigned to each student be-fore and after treatment. These scores were correlated withother data, and conclusions as to effectiveness of treatmentin each instance drawn.

Diagnostic Phase - Medical

Two plain observation mirrors were utilized for better evalu-ation of the students during posture examination. Each sub-ject was examined while sitting and ste.nding before the mir-rors. Male subjects were dressed in gym shorts and females inshorts and a halter. All subjects were examined while bare-footed. A standard orthopaedic postural examination was con-ducted in each instance. This examination included gross ob-servation of posture and gait, strer.gth of all major musclegroups, range of motion of all body joints, etc. (see Exhibit5,in the appendix). Joint contractures were noted and meas-ured. All postural deformities were similarly noted andmeasured. A neurological examination, including deep tendonreflexes, motor power and peripheral sensation with specialevaluation of proprioceptive and kinesthetic abilities wasmade on each student (see Exhibit 50 in the appendix).

Each subject was tested on the verticalometer (Exhibit 6,inthe appendix). This instrument is a four foot length ofhollow aluminum tubing,attached through a ball and socketjoint to a heavy wooden base. Measurements of vertical con-cept were taken with the right hand alone, the left hand alone,and finally with both hands by having the student place the rod"straight up and down". Measurements of verticalometer de-viation in the anterior-posterior and lateral planes were takenwith a bubble goniometer. This technique was used in quan-titating conceptual postural error. Readings were noted andrecorded.

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Each student was observed during ambulation along a thirty foottrack. In the case of the partially sighted subject, a blind-fold was used for this part of the examination. Veering fromthe track was observed and recorded by degree. In cases whereveering was present, wrist weights were applied either uni-or contralaterally,and their effect noted and recorded on arecord sheet. A picture of a wrist weight can be seen inExhibit 7, in the appendix.

Each subject underwent a complete physie rie examination. Suchparameters as body image concepts, muscle tension, orientation,hand function, etc. were measured during this e:mmination. Asample of the form used for recording the physiatric examina-tion can be seen in Exhibit 8, in the appendix.

Diagnostic Phase - Psychological

The verbal portion of the Wechsler Adult Intelligence Scalewas administered to each subject along with a Sentence Comple-tion Personality Check List. The resultant intelligence scoreand personality rating was noted and recorded. Results wereevaluated in conjunction with empirical observations and sub-jective appraisal of the student during clinical interviews,and a psychological diagnosis was recorded in narrative form.

Three special tests were designed to assess tactile form dis-crimination, tactile parallelity discrimination, and tactileturning discrimination.

Form concepts were assessed by noting the student's ability toperceive basic forms (triangle, Greek cross, circle,square) asmeasured by specially designed form-boards. These form-boardsmay be seen in Exhibit 9 in the appendix. Without any training.the student was asked to identify four different shapes in fivedifferent media, and correct verbal responses were noted andrecorded. All forms were then placed in front of the studentin mixed order with instructions to sort out similar shapes andmake four piles of similar shapes. The number correct wasnoted and recorded on the Form Concept Instructions and TallySheet, Exhibit 10, in the appendix.

Parallelity concept was assessed by noting the student's abil-ity to follow a set of nonparallel pieces of wood and reportthis lack of parallelity. This apparatus may be seen in Ex-hibit 9, in the appendix. The student was introduced to theapparatus while the strips of wood were in parallel relation-ship. One board was then changed in 10 degree iutervals to aposition at a 90 degree angle to the fixed board and returned.The student was asked to tactually study the relationship ofthe two boards at each point and verbally report their paral-lelity. Four trials were run and correct responses were notedand recorded on the Test of Parallelity Tally Sheet, Exhibit 11,in the appendix. Examiner's Instruction Sheet can be seen inExhibit 12, in the appendix.

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Turning concepts were assessed by noting the student's abilityto accurately operate a free-wheeling turntable, capable ofrotating 360 degrees, to which a marking device was attached.Degrees were marked off on a surrounding ring of paper. Thisdevice could be seen in operation by a student with an ex-aminer looking on in Exhibit 9, in the appendix. The studentwas instructed to turn the turntable on command 45,90,180,and360 degrees, both left and right. The number of correct turns(accuracy within plus or minus 5 degrees) was noted and re-corded on the Turning Instructions and Tally Sheet,Exhibit 13,in the appendix.

Diagnostic Phase - Miscellaneous

A number of students were programmed through an adaptation ofthe Montessori Training Equipment as an aid in diagnosing andtreating perceptual motor deficits. This apparatus providedan additional parameter for the measurement of motor statusand its correlation with posture and mobility skills. Thisequipment can be seen in Exhibit 14, in the appendix.

An attempt was made to determine the degree and direction ofthe relationship between mobility skill and the results ofperformance on models designed to assess various perceptualconcepts. A clarification of these inter-relationships will,hopefully,lead to 1) a better understanding of the perceptual-conceptual factors involved in mobility training; 2) a tech-nique for predicting possible problem areas in mobility train-ing; and 3) innovations in teaching techniques of mobilitytraining.

Treatment Phase - Mobility

Each student was enrolled in the general orientation and mo-bility program of the Institute. The study group receivedadditional instruction. Education in proprioceptive spatialorientation was approached first by demonstrating posturalhabitue through the use of a life-sized mannequin. Eachstudent was given the opportunity of handling the mannequin,so that the various body and limb positions could be demon-strated kinesthetically, Exhibit 15, in the appendix.

Kinesthetic knowledge of body and limb positions was trans-ferred to a proprioceptive spatial orientation through theuse of a "wind tunnel". A large standing fan, flanked byportable wooden screens, was used to direct an air current onthe student as, dressed in loose gym clothing, he was in-structed to stand in the air current thus created. While inthis location, the student was instructed in the assumptionof a variety of postural stances. He also carried out anyprescribed postural exercises while in the current of air.During this phase of his treatment program he was encouraged

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to verbalize the position of his body and extremities. Inthis manner, sensory input was increased, and the develop-ment of an acute awareness of posture and limb positionduring movement pas accomplished. See Exhibit 16, in theappendix.

Treatment Phase - Medical

Those students diagnosed as having problems of malposture,significant enough to compromise efficient mobility, re-ceived appropriate orthopaedic and/or physiatric treatmenttechniques. These techniques included exercises, when in-dicated, Exhibit 17, in the appendix, and where a specificstructural orthopaedic problem necessitated the use ofrestraints or braces, special apparatus was applied. SeeExhibit 18 and 19, in the appendix. A physical therapistwas employed to develop and apply special exercise tech-niques to meet the particular needs of each student.

Students demonstrating a deficit in balance and spatialsense underwent a progressive series of exercises performedon a trampoline. A physical education specialist was em-ployed to develop and apply special exercise techniques tomeet the particular needs of each student. See Exhibit 20,in the appendix.

Photography Recording Techniques

Recording of gait and posture patterns before, when one half(six weeks) through the program, and after the program wasaccomplished through motion picture photography. This evalu-ation consisted of having the student walk unaccompanied adistance of fifty feet back and forth in front of the cameraand then (again unaccompanied) walk a similar distance to andfrom the camera. Voice commands were used to direct thestudent along these pathways. All photography was performedin the Department of Photography at the University of Il-linois, College of Medicine (Exhibit 21, in the appendix).

Motion picture records, as above described, for each studentin the study sample were collected, identified and placed inrandom order.

Two panels of three experts each reviewed these film sequencesand labeled each sequence as to its proper placement in thechronological order in which it was taken. One panel was com-posed of mobility instructors for the blind, the other ofspecialists in physical therapy and postural training. Thus,the sum of the assessments of two separate disciplines wasobtained.

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Each expert made his judgment independently. The total num-ber of correct responses of all six experts made, by correctlyidentifying the proper order in which each film sequence wastaken for each student, with the improvement score for eachstudent. Therefore, a perfect improvement score oould be ob-tained by having all experts correctly identify the properorder of all three film sequences of one student. The maxi-mum score would be three sequences times six experts, or 18.

The actual score for each student in the sample was noted andrecorded. The distribution of scores was plotted and dividedinto three parts. Those receiving the lowest improvementscores were labeled "poor improvement" (C), those receivingmiddle improvement scores were labeled "moderately improved"(B), and those receiving the highest improvement scores werelabeled "markedly improved" (A).

It was then possible to study the results in terms of theseclassifications. Demographic characteristics, performance onall diagnostic apparatus, and psychological traits were ex-amined to discover relationships which might be of significantpredictive value. The types of postural deviations whichrespond to treatment, as measured by improved mobility skills,were identified.

Physical Therapy Techniques

In order to achieve effective mobility, the blind student musthave good posture and balance. In addition, his concepts ofbody image and basic orientation in space should be adequateand accurate. Within these areas, physical therapy can con-tribute to mobility training.

An evaluation must be made before physical therapy techniquesutilizing only nonvisual cues or aids can be instituted to de-velop good posture and sensory awareness, Some of the physicaltherapy techniques currently in use and under investigation atthe Illinois Vispaily Handicapped Institute in Chicago arepresented here.

Evaluation

The accompanying form,which is currently being used for physi-cal therapy evaluation, covers three basic areas: 1) physicalcharacteristics and abilities; 2) gait; and 3) concepts ofbody image and orientation (Exhibit 8, in the appendix).

First, the evaluation form is used to test all physical orpostural defects, such as head drop, abdominal protuberance,lordosis, 'r scoliosis. Any weakness or limitation of motioncan be discovered through manual muscle testing, examinationof joint range of motion, and muscle length tests. Duringthese examinations the student's state of tenseness or relax-ation is recorded, and his coordination and balance are tested.

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Second, the student's gait is observed to determine whetherit is wide-based and out-toeing, hesitant and shuffling, orpropulsive and unsteady, and whether veering is present.

Third, an attempt is made to determine the student's conceptof body image, primarily through questions concerning re-lationships of various parts of the body, verbal descriptionsof body parts, and tests of his ability to perform accuratemotions in response to simple commands.

A test is also made of the student's execution of turns.Finally, to assess his ability to acquaint and orient himselfin strange surroundings, he is asked to perform activitiessuch as pointing to the door he used to enter the room orfinding an object located on a particular wall in the room.The number of attempts he makes, and the amount of additionalassistance he requires to perform these activities, are ob-served and recorded.

With the exception perhaps of the tests for muscle strengthand length, this evaluation is subjective and somewhat super-ficial. Rather than attempt to pinpoint very precise anddetailed problems, the evaluation tries to establish broadand basic areas of difficulty which may then be approachednot only by physical therapists but also by personnel in re-lated disciplines.

Following the first evaluation and at intervals during treat-ment, the student's ability and progress are rated on a scaleranging numerically from one to five (Exhibit 22, in the ap-pendix).

Treatment

After completion of the evaluation, a suitable treatment andtraining program is instituted. First, a general exerciseprogram is established to fit the needs of each student andcarried on daily in class under the supervision of the in-stitute's Physical Education Department. This program isdesigned to provide adequate muscular ability, promote relax-ation, and improve coordination.

Muscle Strength and Length

The most common areas of muscle weakness include trunk,neck,and hand musculature. Limitation of motion is often presentin the scapular and back regions and at the hip and ankle.Conventional exercises are used to correct these problems,

Relaxation

To help reduce tenseness and rigidity, especially of the up-per extremities, the student first learns voluntary contrac-tion and relaxation of large muscle groups in connection with

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breathing. Then he proceeds to isolated and reciprocal mo-tions which call for contracting one part while maintainingrelaxation in the rest of the limb or body.

Coordination

Coordination is very often a problem for the blind child,possibly because he does not have opportunities to partici-pate in activities which promote natural development of co-ordination. Therefore, some time is devoted to activitiessuch as rolling, crawling, and balancing on all fours.

To aid in improving basic coordination and development, theinstitute recently began using the Exer-CorR machine whichis designed spacifically for cross-patterned creeping exer-cises. Assuming the crawling position, the student placeshis hands and knees on four small pads which are on tracks,and learns to pattern,incorporating head movement with hisarms and legs (Exhibit 23, in the appendix). The machine'sconstruction requires the student to use his own musclestrength, but he is able to move only in the desired pattern.Straps and other devices help hold the hands and legs inplace,if necessary, and the instructor stations himself be-hind or in front of the student for assistance in the be-ginning stages.

To improve strength and coordination of the hands, the stu-dent is taught reciprocal hand movements such as alternateopening and closing of fists. He also works at the handactivities table which, by use of pulleys and weights, pro-vides resistive exercises for even the smallest muscles inthe hands and fingers (Exhibit 24, in the appendix). Otherdevices which are used include exercise putty, various typesof grippers, and wrist and finger rollers.

If the blind child has any other disability - scoliosis,postpoliomyelitis, or cerebral palsy - specific, conventionalexercise programs are incorporated into the total treatment.

Postural Training

When the general exercise program is under way, actual pos-tural training is given. Success has been achieved with agroup of exercises adapted from exercises previously used forpatients with low back pain and weakness. These exercisesare based on a reduction of the curve in the lower back, whichis accomplished by contracting the abdominal and gluteal mus-cles that result in a flat back. The student learns not onlyto perform this contraction as an isolated activity, but also tomaintain that posture while performing other motions and in con-nection with breathing.

These exercises are taught to a group of five or six students.

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The group atmosphere is conducive to more discussion andexperimentation and, therefore, to a meaningful learning ex-perience. In addition, postural exercises lead into thecontrol of trunk muscles, which plays an important role inbalance.

Gait Training

Another phase in postural rehabilitation is the correction offaulty walking habits. This phase involves a variety of tech-niques for training of heel-toe gait, maintaining a stable,narrow base of support, eliminating out-toeing or head drop,maintaining relaxed upper limbs, and improving tracking. Mostof these defects can be approached much as they would be in asifshted person. However, some nonvisual aids can be used foretch gait training.

The treadmill (Exhibit 25,appendix) is useful for teachingheel-toe gait because it cannot be operated in any other man-ner, and because the narrow width of the treadmill beltlimits the base of support.

Another device used to teach correct positioning of the feetis the slant board (Exhibit 26) or inversion board (Exhibit27). Because the student walks along the sloping board withhis toes touching the raised center strip, out-toeing is dis-couraged.

A soft cervical collar may occasionally be used as a tempo-rary reminder to discourage head tilt or drop. This measureis designed to draw the student's attention to a posturaldefect he cannot see.

To help promote a more natural relaxed arm swing during gait,the crook of a long cane may be placed in each of the student'shands. The therapist grasps the opposite ends of the canes andwalks in tandem. The student projects his arm swing to thetherapist's as they walk (Exhibit 28).

Weighted wristlets on the contralateral arm are also used attimes to correct excessive veering in gait.

For the other two areas of the physical therapy training pro-gram, body image and orientation training, the techniques usedmust of necessity be newer and more unusual than any othersdiscussed. The blind child needs a great deal of special helpin these areas in order to develop a sound mental picture ofhimself, of the world around him, and of his relationship tothat world. The institute is currently experimenting withseveral techniques developed for this purpose.

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Body Image

One of the greatest aids ir teaching the concepts of bodyimage is the full-sized, articulated mannequin. First, thestudent uses his tactile sense to explore and learn some-thing about the human body and the relationships of its parts.Later, through questions, demonstrations, trial and error,andimitation, the student begins to learn not only what his ownbody looks like but how, where, and why it moves as it does.

Hopefully, in the future someone will design a life-sizefigure which will be even more realistic in regard to tex-ture,temperature, joint structure, and other features per-haps a figure like those now used in some medical and nursingschools for training in anesthesiology and artificial respi-ration. However, even a storewindow mannequin provides abeginning.

Orientation

To help develop the student's orientation to his surroundings,a fixed object, such as a wall, is initially used. Against thewall he performs motions such as flexion and abduction of thearm at the shoulder joint, and abduction and rotation of theleg at the hip joint. The emphasis is on accuracy. Instruc-tion in making accurate turns also begins at the wall,usingthe relationship of the body to the wall to determine 90-,180-,and 360-degree turns. The 90-degree turn is stressed be-cause of the importance of accurate turnr in mobility. Forthis purpose, two wails may also be used the student placesthe entire back of his body against the wall being trailed bythe hand or cane in order to make an exact 90-degree turn.

Later, less fixed clues are sought, such as the resistance ofthe body to a strong wind. To gain this effect, a floor fanon a relatively tall base and two portable walls are used toform a type of wind tunnel. Again, the student learns jointmotions and turns through wind resistance on a particular bodypart or surface to determine accuracy. Initially, the fan'shighest speed is used, and the speed reduced as the studentimproves. Eventually, of course, the student must proceed tosimilar activities without any aid.

To utilize better the student's sense of touch in orientationtraining, a carpeted, wooden tunnel was devised to shrink hissurroundings, so to speak, to a point where he would be ableto come in physical contact with a larger area at one time(Exhibit 29). The tunnel is three feet square, with threeseparate straight sections of nine feet each, and two curvedcorner sections. This construction allows the therapist toarrange the tunnel in several shapes.

The students use the tunnel in groups. They are told only

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that they will be crawling through a structure which is com-pletely safe. Each student is introduced to the entrance ofthe tunnel,and then placed on his knees and allowed to makehis way through it, silently gathering as much information aspossible about it.

After all the students emerge, the group decides what the ob-ject is, what it is made of, how large it is and of whatshape, how many parts and corners it has, and so on. Thisexercise ueually provoker considerable response and enthu-siastic discussion, The students attempt to picture the tun-nel in their minds and then to relate some of the ideas andconcepts they have learned to everyday objects and experi-ences, Later, the students who judged incorrectly or haddifficulty grasping some concept are taken back to the tun-nel and given a chance, with assistance if necessary, tolearn the correct answers. The shape of the tunnel may thenbe changed and the group allowed to try again.

This activity has proved useful not only to the student'slearning program, but also to alert the therapist to specificconcepts which the students lack or find difficult.

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Special Clinical Report

Postural Compensation in the Motor-Handicapped Blind

Vision is such a stunning sense that its use for posturalorientation all but completely dampens other sensory modali-ties. If the body is to attempt postural compensation in theface of visual loss, input through remaining senses must beabundant enough to enable the subject to successfully con-template his stance and movements.How can this be accom-plished? Examination reveals that not only the solely bio-mechanical and 'mythological factors, but the perceptivevariables as well are important, e.g., blindness is oftenonly one aspect of a larger neurological loss, motor per-ceptual disability also being present. This is particularlytrue in cases of congenital blindness in which marginal braindamage has occurred. Thus, postural training should never beconducted in a void. Exercises are performed best with ref-erence to a vertical surface, such as a wall. Sensation oflimb position in space is enhanced by exercising in front ofa large fan. The correct "feel" of upright carriage can belearned only through repeatedly enforcing the engrain gainedby such proprioceptive feedback. The use of tumbling, tram-poline drill, or any other activity designed to increasekinesthetic input is of value in laying the ground work forpostural refinement.

Although the kinesthetics of ambulation have not yet beenfully elucidated, it is apparent that the difference betweenabnormal and normal gait patterns is one of degree rather thankind. The same mechanisms for security and balance which theblind are required to use can be noted in the sighted duringperiods of normal growth, unusual stress, temporary loss ofvision, or other situations in which the apparatus of secon-dary posture control is employed. In this regard, wide-basedout-toed gait is seen in the sighted infant taking his firststeps, as well as the sighted adult attempting to maintainbalance on a steep incline. Even so-called "blindisms" arenot peculiar to the blind. Head rocking is not unoommonamong otherwise normal infants where it is used as a self-stimulatory mechanism to "keep in balance" psychologically aswell as physiologically. It is of interest to note that thisautomatism is often employed at bedtime in the dark. The useof such techniques by the blind, as by the sighted, may beeffective, but their cost in energy to the organism makesthem inefficient in the extreme.

The postural problems of the partially sighted are often asserious as those of the blind and partially deaf, particularlywhen sight or sound perception is only unilaterally present.Such individuals tend to point with the functioning organ andusually veer to that side. During rehabilitation blindfoldingthe sighted eye may be necessary, at least in the initialphase of mobility training. Cccluding one ear has also been of

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value in correcting a tendency to veer.

Many factors are involved in postural compensation,and theyare often difficult to measure. For instance, the properuse of the Hoover long cane involves a cross-patterning ofbody movement. Several of our multiply handicapped pupilshave been taught cross-patterning and crawling before beingintroduced to the cane. Such preliminary instruction seemsto facilitate the early phases of cane training.

A complete orthopaedic and neurological evaluation, includingan examination of stereognosis, position sense, and tactilekinesis, can offer clues to the particular needs of eachstudent. In meeting these needs, special techniques must bedeveloped and applied, particularly when blindness is com-pounded by motor loss. In these instances, rehabilitation isat best difficult, but meeting the challenge is often re-warding.

A group of case reports describing some postural problemsseen in the motor-handicapped blind follows. Each summary il-lustrates the nature of the problem and its treatment, fol-lowed by comments.

A twenty-three year old blind female had a variety of ortho-paedic defects. She was the product of a normal pregnancyand delivery and had met her motor milestones at the averagetimes. But, when she was twenty months old, she sustained abrain injury which left her a spastic quadriplegic and totallyblind.

She had dealt with her blindness and motor problems reason-ably well, having completed high school at a nonspecial fa-cility. Numerous surgical procedures performed to increasestability in her lower extremities and extensive attempts atphysiatric rehabilitation proved only moderately successful.A tendency toward recurrent depressions added to her organicproblems.

Examination revealed a typical spastic gait with mild tomoderate spasticity in the upper extremities. She had dif-ficulty with balance and walked with the aid of crutches. Aprogressive spinal curvature complicated her postural prob-lems. Hip flexion contractures were severe, but the feetwere plantigrade. There was an increase in lumbar lordosisas well as adduction and internal rotation contractures ofthe right hip. A lack of supination of the right wrist wasalso noted. Neurolt,gical examination revealed good tactilelocalization, stereognosis, position nense, graphesthesia,weight perception, vibratory sense, and two point discrimina-tion. No gross loss of motor perception could be detected.

Gait and ambulation training and rehabilitation exercises,

including stretching of the flexors of both hips, were ini-tiated under the supervision of a physical therapist. Ini-tially, it was necessary to drill the student in creeping,crawling, and cross-patterning. Subsequently, appropriatepostural exercises were utilized which were performed in frontof a 10Tge fan. Emphasis during her training was placed onbalance and contracture stretching in the lower extremities.She progressed from two-crutch walking with one hand on asupporting rail.

Close observation during training revealed that hip adductionand internal rotation deformities on the right were seriouslyimpairing her gait, and a surgical operation was performed toamend this. She has continued to improve since this surgery.

Appropriate orthopaedic evaluation and attention can prove ofvalue in the rehabilitation of the motor-handicapped blindstudent. In this case, a series of surgical procedures, com-bined with an intensive program of physical therapy, expe-dited the patient's motor rehabilitation. Good balance andcoordination were major problems. Emphasis was originallyplaced on mat exercises. Later, a sequential program ofbalancing on all four limbs, creeping crawling, andainally,standing balance exercises were followed. Kinesthetic inputwas enhanced by performing the exercises in front of a largefan.

A thirteen year old congenitally, totally blind female had amoderate spinal curvature with increased lumbar lordosis. Shehad e severe bowing of the knees, and anterior curvature ofboth thighs and legs. Her trunk was foreshortened, her fin-gers reaching approximately to the level of her knees. Shehad a history of multiple fractures of the lower extremitiesduring early childhood, all of which healed without incident.X-rays were taken which revealed the stigmata of osteogenesisimperfecta tarda. The postural problem was essentially one ofbalance of the trunk and upper limbs over the lower extremi-ties.

A standard program of postural exercises, mobility, and ori-entation training was initiated. Because of her bony deformi-ties this patient progressed more slowly than the average,but she was bright, alert, and well motivated, and eventuallywas able to travel as well as her fellows.

Most of the deformities noted in this case were attempts tocompensate for structural abnormalities in the back, hips,andlower extremities. No attempt was made to correct these de-formities surginally because the patient's segmental balancewas in compensation and she was functionally stable.

Because of the anterior bowing of her thighs and legs, herweight bearing line was forced posterior to her knees,andher back condition represented an effort to maintain the erect

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position. It is important to note that in a rehabilitationprogram functional restoration should supersede cosmetic cor-rection. Efforts to obtain better appearance alone oftenresult in poorer performance.

A twelve year old totally blind female had spastic quadri-plegia. She had undergone numerous orthopaedic procedures togain stability about the feet and ankles. She could barelystand, using a heavy cane in her left hand. Some left torsoshift was present,and flexion contractures of the elbows,wriste, hips, and knees were noted. There was severe pesplanus with ankle valgus.

This patient had no concept of verticality. She walked witha hesitant wide-based gait. Her balance was tenuous. Sinceshe required a heavy stick for stability while walking, shecould not use the long cane.

Balance exercises were prescribed. Ambulation was startedwith the patient tethered to the instructor with a light belt.A modified light cane which was short enough to provide sta-bility was provided. Gradually less support was required. Noeffort was made to correct her posture beyond what was neces-sary for effective ambulation.

The "jump position" and wide-based gait were maintained inthis student as they contributed to stability. Balance exer-cises, combined with gradual weaning from support,enabled herto eventually discontinue the use of a heavy cane and to use along one effectively.

A nineteen year old consenitally,totally blind male had beendiagnosed as a spastic paraplegic. His gait was characterizedby spastic circumduction. His posture was compromised by in-toeing and a wide-based stance. There was difficulty withbalance,and an increase in lumbar lordosis with a flexibletorso shift was also noted. His tendency to veer to the rightwhen tracking was corrected by placing a weight on the leftupper extremity. Bilateral hip flexion contractures werepresent. The student could not stand on one foot alone, andwalking on the heels and toes was impossible because of footdeformities. Neurological examination failed to reveal motorperceptual deficit.

A 7anual muscle examination was performed and appropriatestrengthening exercises, as well as balance drill and con-tracture stretching, were started. The student was given aregimen of physical therapy and physical education.

Frequently, the standard mobility program must be modified toaccommodate a student's disability. An accurate manual muscleexamination can reveal specific motor loss and aid greatly instructuring a rehabilitation program. Veering tendency can

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often be corrected by weighting on an upper extremity.

A seventeen year old totally blind male had neurofibromatosisand a secondary optic nerve tumor. He was overweight andhad the obvious stigmata of his disease including multipleskin lesions and neurofibromata of the superficial nerves. Hewas very clumsy in his gait and posture, and walked with aheavy out-toed gait. A mild dorsal kyphos was present. Psycho-metric testing revealed that he was functioning intellectuallyat approximately the seventh grade level.

Postural exercises were initiated and as he had some diffi-culty with motor learning tasks, special tactile learningtechniques were employed. These utilized Montessori instruc-tion and emphasized gross form recognition and manipulation.A program of trampoline drill was begun. Through thesemeasures the patient improved. His posture has become moreacceptable and his gait less clumsy.

Basic form recognition and manipulation provide excellentpreparation for the performance of gross motor tasks. TheMontessori apparatus and techniques can help to develop suchskills in the blind. The balance requirements of trampolinedrill offer a kinesthetic experience which tends to exerciseand refine motor perceptual abilities.

A sixteen year old male had a history of congenital, totalblindness. In addition, he had been given little opportunityto move independently or, in any way, to experience the worldaround him. Neurological examination revealed a congenitalcerebral defect involving the occipital cortex and certainsensory centers producing a postural ataxia. The studentengaged in frequent lateral head rocking with hyperkineticmotions in all extremities. He moved very rigidly and wasconstantly off balance. A mild mid-thoracic scoliosis wasnoted. The gait was rigid and wide-based, and marked pesplanus was present. His head was held turned toward the leftwith the chin elevated, and there was gross muscle wasting inall extremities including the small muscles of the hands.

A full program of posture training, including relaxing exer-cises and standard physical education drill, was initiated,A 7ariety of sensory stimulating activities, including theuse of a full-sized mannequin for demonstration of body partsand position, were programmed. The student continues on thisregimen and has shown progressive improvement.

The proper treatment of sensory deprivation is the provisionof lavish stimulation. All manner of kinesthetic= experiencewill be offered this student. As his balance and mobilityskills improve, more refined techniques will be used. Thesemay include barefooted ambulation on textured runners as a

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supplement to standard mobility training. The use of a full-sized mannequin has proved of value in this case in helpingthe student structure an appropriate body image.

The postural apparatus in the blind is severely compromisedby motor disability. However, rehabilitation can still be ef-fective through the use of special techniques suitably tailoredto the requirements of the individual student.

Each of these cases illustrates certain of these needs. Manyorthopaedic and neuisological diseases can be complicated byblindness (e.g. gargoylism, Friedreich's ataxia, Marfan'ssyndrome, etc.) and blindness can compound any motor problem.The therapy of malposture requires clarification of the '6asiccause(s) of divergency (biochemical, psychological,perceptual,etc.) with treatment aimed at functional correction. In thisway, optimal rehabilitation can be accomplished.

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Results

General Remarks

Total population was 45 subjects, except for psychometrictesting where total population was 41 subjects.

Table 1 details the diagnostic/treatment matrix.

There was no significant correlation between age, sex,orintelligence quot:ent, and any of the improvement orachievement scores.

Chart 1 illustrates improvement in posture, evaluated on thepostural physical therapy scale and correlated with finalimprovement score.

Chart 2 illustrates improvement in mobility, evaluated onthe mobility improvement scale and correlated with finalimprovement score.

Charts 3,4 and 5 illustrate the three psychometric tests;1) gross form recognition; 2) manual transcription of vari-ous arcs of a circle; and 3) parallelity recognition) cor-related with final improvement score.

Chart 6 illustrates degree of improvement in postural ther-apy, correlated with degree of improvement in mobility.

Scoring Key for Data Charts

Posture Therapy

S - Same score before and after therapy.Numbers represent improvement in scores before and after ther-apy.

Lx. Rating Scale: 1 - 5Score: Before After

1 (improvement)Mobility

S - Same score before and after mobility training.Numbers represent improvement in scores before and after mo-bility training.

Ex. ating Scales Poor,Fair,Good,Excellent, SuperiorScores Before After

2 TiMprovement)

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psychometric Tests

1 - Raw scores on a scale 1 - 5

2 - Numbers represent rating scaleRaw Score Rating25 - 39 1 (low)40 - 54 255 - 60 3 (high)

Chart 1 - Improvement in Postural Therapy

Correlated with Final Improvement Score

Of 20 students with a final improvement score of As

1) Five students (25%) did not improve in postural therapy.However, it is significant that of those five, four al-ready had achieved a high score in postural therapy(score of 4- or above). Only one student remained thesame with a low score.

2) Eight subjects (40%) improved one third, but one half ofthese already had high scores in therapy (4- or above).

3) Seven students (35%) improved significantly.Five students improved two thirds.One student improved one.One student improved one and one third.

Data concerning students with a final improvement score of Bis not statistically significant because the sample (eight)is inadequate. However, four improved and four remained thesame. Three of those not improving were already at a highgraded level in posture therapy.

Of 17 students with a final improvement score of C:

1) Seven students remained thethese, five were already at

2) Five students improved oneready at a high level.

3) Five students made significant improvement.Four students improved two thirds.One student improved one.

Of the total subjects (45) tested:

1) Sixteen students remained the same. Of these, twelve(75%) already had high scores in postural therapy.

same in postural therapy. Ofa high level (4- or above).

third. One of these was al-

SG

46

2) Fourteen students improved one third. Five of these werealready at a high level in postural therapy.

3) Fifteen students (33-1/3%) made significant improvement.Nine improved two thirds.Three improved one.Three improved one and one third.

Thus, all students either improved or remained the same inpostural therapy. Of those remaining the same, 75% were al-ready at a high level.

Chart 2 - Improvement in Nobility

Correlated with Final Improvement Score

Of 20 students with a final improvement score of A:

1) Five (25%) remained the same. it is sigrificant thatof these four were at a poor level.

2) Twelve (60%) improved one.

3) Three (15%) improved two.

Eight students had a final improvement score of B. Data hereis too scant for statistical significance.

Of 17 students with a final improvement score of C:

1) Eight students remained the same, but of these, six be-gan at a poor level.

2) Seven improved one.

3) Two improved two.

Of the total number (45) tested,

1) Fifteen students (33-1/3%) remained the same. Eleven ofthese were at the poor level.

2) Thirty students (66-2/3%) improved.Twenty-three improved one.Seven improved two.

Thus, approximately 50% of those with original poor level mo-bility scores tended to remain the same. The remainder im-proved after treatment.

Chart ( Psychometric testing of gross form recognition) andChart 4 (Psychometric testing of manual transcription of arcsof a circle) illustrate no significant cJrrelationotthese

JO

47

tests with final improvement scores, nor was there any cor-relation, positive or negative, of these several psycho-metric examinations with any postural or mobility parameterof achievement score.

Chart 5 - Psychometric test of Manual Parallel Dis-

crimination, correlated with Final Improvement Score

Of 18 students with a final improvement score of Ai

1) Four had a rated score of one (low).

2) Three had a rated score of two.

3) Eleven had a rated score of three (high).

Of eight students with a final improvement score of B, datais of minimal significance.

Of 15 students with a final improvement score of CI

1) Six students obtained a rated score of one (low).

2) Three students had a rated score of two.

3) Six students had a rated score of three (high).

These results show a significant correlation between theability to manually ascertain parallelity and the final im-provement scores of the students. Thus, this psychometricexamination may have predicitive significance.

Chart 6 - Improvement in Postural Therapy

Correlated with Improvement in Mobility

Of 15 students remaining the same in mobility:

1) Five remained the same in postural therapy. These werealready at a hi3h level in therapy.

2) Five improved two thirds in therapy.

3) Three improved two thirds in therapy.

4) One improved one in therapy.

5) One improved one and one third in therapy.

Of the 21 students obtaining an improvement score of one inmobility:

1) Eight remained the same in therapy. Six of these students

48

were already at a high level in therapy (4- or above).

2) Seven students improved one third in therapy. Of these,four were already at a high level.

3) Four students improved two thirds in therapy.

4) Two students improved one in therapy.

5) Two students improved one and one third in therapy.

Of seven students obtaining an improvement score of two inmobility:

1) Three students remained the same in therapy. All threewere already at a high level in therapy.

2) Three students rated an improvement score of one thirdin therapy. Of these, one was already at a high level.

3) One student improved two thirds in therapy.

Thus, 28 of 45 students tested demonstrated a positive cor-relation between improvement in mobility and improvement inpostural therapy.

Discussion and Implication of Results

As noted,noted, analysis of data fails to indicate correlationbetween age, sex, or measured intelligence quotient, and anyvariable, including postural therapy improvement, mobilityimprovement or final improvement score. We also note thatthe degree of orthopaedic or neurological deficit does notnecessarily affect improvement potential. The majority ofstudents (29 of 45) showed improvement in posture undertreatment. Of those not improving (16), 75% had highpostural therapy scores to begin with. Approximately twothirds of all students tested improved in mobility, and ap-proximately 50% of those with original poor level mobilityscores improved after treatment. Almost two thirds of allstudents tested showed a positive correlation between im-provement in postural therapy and improvement in mobility.

Additionally, although lack of correlation between psycho-metric tests 1 and 2 with postural therapy, mobility, orfinal improvement scores was disappointing, it was encouragingto note the high positive correlation of psychometric test 3(manual parallelity discrimination) with the final improvementscore. This test may, indeed, have a predictive and prog-nostic value in predetermining those students who might beexpected to excell in a postural training - mobility program,such as described,

JO

149

The implications of these results are simply stated.

1) Postural training contributes to mobility skill.

2) Even those students with a low intelligence quotient andsevere orthopaedic and/or neurological deficits can be pro-grammed successfully through postural training with sub-sequent improvement in their ability to orient and travel.

The parameters of posture can be utilized in the training ofmobility skills in the blind. Improvement in these skillscan be clinically evaluated through the methods described.

Orthopaedic evaluation and postural therapy can play apositive role in the total rehabilitation of the blind, thussignificantly contributing to vocational potential.

JU

Diagnostic Treatment Matrix

No. Init. Age Sex

Ortho-Neuro-Findings

1.

T.A.

27

M

2.

F.B.

26

M

3.

B.F.

40

F

4.

C.F.

23

F

5.

W.G.

20

M

6.

B.G.

18

Left torso shift. Wide-based gait.

Hamstring tightness. Right veering.

Posterior deviation on verticalo-

meter. Poor stereognosis and shape

discrimination.

Slight imbalance

standing on each foot.

Moderate kyphos. Hesitant gait.

Tight hamstrings. Decreased sensa-

tion in soles. Diabetic neuropathy.

Absent reflexes in lower extremi-

ties.

Poor orientation. Points with left

ear. Mild ataxia.

Pes planus. Valgus knees. Cautious

gait. Wide-based. Years right.

Posterior verticalometer error.

Head droop. Tense.

Loose jnints. Flat feet. Poor

orientation. Very tense. Head droop.

Mild kyphos. Tight hamstrings.

Ankle clonus bilaterally. Disco-

ordination. Tight Achilles. Slight

imbalance.

Excellant postural patterns with no

neurologioai or orthopaedic prob-

lems of note.

Table 1

Therapy

BABAIQIII

Mobility

Psych.

III

Improvement

Score

23

PP

76

129

148°

12 - A

44

FG

97

360

175°

6 - C

44

PP

79

160

170°

11 - B

34

PF

91

153

1300

8 - C

23

PF

107

252

135°

11 - B

44

GE

114

355

176°

12 - A

No. Init. Age Sex

Ortho-Neuro -Findings

Therapy

B

7.

W.K.

20

MCSP. Bilateral triple arthrodesis.

23+

Tendon transfers and osteotomies

hips. Intoeing. Kyphos. Spastic

circumduction gait. Torso shift with

increased lordoxis. 300 hip flexion

contracture. Lurching gait. Moderate

anterior vertioalometer deviation.

Tandem gait impossible and heel and

toe walking impossible. Atrophy of

lower extremities.

8.

J.M.

27

F2+

2+

9.

M.P.

18

MPee planes. Propulsive gait. A.P.

33

rocking.

10. J.R.

19

MPartial loss. Good posters and no

44

neurological deficit.

11. B.S.

18

FPoor balance. Hyperreflexia. Bight

23+

torso shift. Head drop. Mild kyphos.

Pes planes. Rigid gait with small

hesitant steps and wide-based with

outtoeing. Imbalance and tension.

12. W.S.

26

FObese. Genu valgum. Mild kyphos.

44

Slouching. Mild pes planes. Slight

veering to right. All deep tendon

reflexes decreased.

Wide-based outtoeing gait. Pes

planes. Obese.

13. V.S.

53

FAta'ic gait secondary to cerebellar 4

4damage. Right hypoactive reflexes

upper and lower extremities. Poor

right heel to knee test. Finger to

nose test (left worse than right)

pos. Unsteady gait with imbalance.

Mobility

BA

IQ

Psych.

III

III

Improvement

Score

PF

106

355

1600

11 -B

PP

118

255

135°

4 -

c

GE

97

355

1770

11

B

GS

360

178°

13 -A

PF

89

155

157°

10 -B

GB

69

546

170°

14 -A

FG

89

260

175°

7-

No. Init. Age Sex

Ortho -Neuro -Findings

Therapy

Mobility

14.

D.P.

25

M

15.

P.S.

29

M

16.

J.H.

45

M

17.

W.S.

19

m

Left tilt and torso shift. Mild

pes planus. Left verticalometer

error with right and both hands.

Veers to left.

All reflexes de-

creased. Decreased tandem gait and

decreased balance.

Slight imbalance. Decreased ox-

ternal rotation hips with positive

Faber. Slight right veering.

Dupuytren's contracture palms.

Aoromegaly. Severe kyphos. Severe

imbalance. Slow hesitant gait.

Bunions. Hammertoes. Severe pes

planus.

Left head tilt, right hip elevated

secondary to left thoracic right

lumbar,severe, rigid scoliosis. Poor

graphesthesia. Poor weighing per-

ception. Fair balance. Left anterior

verticalometer deviation of 150 in

each direction when measured with

right, left, and both hands. Poor

body concepts.

18. D.C.

20

FObesity. Poor tandem gait. Pes

planus. Poor concept of joint mo-

tions, poor body concepts.

19. M.B.

21

MDecreased right Achilles deep ten-

don reflex.

Psych.

BABAIIII

III

44+

Gs

108

06o

1700

44+

FG

121

260

180°

33

PP

--

2+

3P

F77

050

120°

33+

PG

78

153

153°

4+

4+

FE

75

160

1300

Improvement

Score

16 - A

2 - C

9 - C

16 - A

_No. Init. Age Sex

Ortho-Reuro-Findings

Therapy

Mobility

Psych.

Improvement

BABA IQ

III

III

Score

20. R.H.

17

MSevere sensory deprivation.Postur-

2+

3+

PP

027

138°

9 - C

al ataxia.

Cannot comprehend ver-

tical concept.

Left torso shift.

Head tilt to left with chin up.

Cannot stand on each foot alone.

Precarious balance.

Wide-based

gait.

Rigid, small steppage. Bight

thoracic left lumbar scoliosis.

Pectus excavatum. Pes planus. Tight

knees. Defect in stereognosis.

Hyperactive reflexes.

Lateral head

rocking. Inverted hips with valgus

subluxans. Hyperkinetic motions in

both upper and lower extremities.

Gross muscle wasting. Rigid back.

Poor body concepts.

21. A.K.

23

MPes planus.

22, M.L.R,21

FRight eye pointing. Pee planus.

Verticalometer deviation of 100 to

left when measured with right,left,

and both hands. Poor body concepts.

23, H.B.

20

FMild kyphosis. Fair balance. Poor

tandem gait. Mild talipes equino-

varus, left. Tight right Achilles

with atrophy right calf,and short-

ening right foot, and shortening

below knee.

24. A.M.

24

MPoor gait and balance. Poor tandem

gait. Poor heel and toe walking.

Pee planus. Slight veering to left.

4+

4+

GE

120

560

128°

4 - C

4-

4G

E100

458

83 0

13 - A

3+

4-

GS

96

260

130°

5 - C

34-

GG

125

347

1500

4 - C

U

No. Init. Age Sex

Ortho-Neuro-Findings

25. K.N.

18

NPoor balance. Poor tandem gait.

Right thoracic left lumbar

scollosis. Pes plans. Verticalo-

meter deviation of 200 posterior

and 50 to right when measured

with right hand. Poor body con-

cepts.

26. S.D.

19

NElevated left shoulder. Poor

balance. Poor heel and toe walking.

Poor tandem gait. Left head tilt.

Pee plaints. Slight veering to left.

ringer to nose test poor on right.

Congenital deformities of fingers.

Facial asymmetry. Webbing of toes.

Verticalometer deviation of 100

anterior when measured with left

and both hands. Poor body concepts.

27. B.S.

19

NPoor tandem gait. Stiff balance.

Clelodactylism fifth fingers. Ver-

ticalometer deviation 150 anterior

when measured with left hand. Poor

body concepts.

28. R.W.

48

FObese. Pes planus. Veers to right.

29.E.W.

58

NToe amputation for diabetes. Poor

balance. Poor heel and toe walking.

Poor tandem gait. Na planes.

Tendency to veer. Fair spatial

localization. Reflexes decreased in

lower extremities. Two point dis-

crimination poor. Vertioalometer

deviation of 150 to loft when meas-

ured with right hand100 anterior

when measured with left hand.

Therapy

BABA

NobilityIQIPsyh.

II

III

Improvement

Score

34-

PF

76

025

1280

13- A

3-

3F

G75

053

1730

13 - A

33+

FG

100

153

1580

16 - A

44

PG

98

045

1630

10 - B

4-

4F

G100

457

1700

14

A

No. Init. Age Sex

Ortho -Neuro -Findings

30. B.N.

21

NVertioalometer deviation of 50

anterior when measured with right

hand and 100 anterior when meas-

ured with left and both hands.

31. M.E.C.19

FPair spatial localization. Intel-

leotually poor. Stereognostic

recognition. Vertioalometer devia-

tion of 150 posterior and 100 to

the right when measured with right

and left hands, and 200 posterior

when measured with both hands.

Poor body conoepts.

32. W.N.S.41

FDeoreased Achilles tendon reflexes.

Poor two point discrimination. Ver-

CD

tioalometer deviation of 250 an-

1%,!

terior when measured with right

hand 35o anterior with left hand,

and 400 anterior with both hands.

Poor balanoe.

33. L.S.

29

NNegative.

34. P.L.

31

FThoracic kyphosis. Pea planus.

Veering to right. Deoreased range

of motion right glenohumera1 joint

with frozen right shoulder. Poor

weighing perceptionayperesthesia.

Absent patellar and Achilles re-

flexes. Decreased two point dis-

crimination. Vertioalometer error

of 200 anterior when measured with

left and both hands.

Therapy

BA

Nobility

BA

IQ

Psych.

III

III

Improvement

Score

4- 2+

3+

4+

4+

4-

3-

4-

4+

5-

P P P G P

F P P E G

125 56

98

4 3

56 60

1180

1430

10 - B

7 - C

12 - A

9 - C

15 - A

NO. Init. Age Sex

Ortho-Neuro-Findings

35. B.W.

24

FGross spasticity. Previous history

of operations, right knee and left

heel. Positive Romberg. Poor bal-

ance. Poor heel and toe walking.

Poor tandem gait. Drags right foot.

Pes planus. Slight ataxia. Spas-

ticity in all major joints. Heel

cord contracture of 10-150 bi-

laterally. Right finger to nose

test poor. Dysdiadochokinesia

present. Poor spatial localization

on right.

Poor ab- and adduction

fingers on right. Poor position

sense on right. Hyperactive reflexes

with negative Babinski responses.

Poor manual dexterity. Obese. Wil-

gus right knee. Right hemiparesis.

Heel to knee test poor on left.

Poor body concepts.

36. F.S.

17

MOuttoeing with wide-based gait and

pea planus. Vertioalometer error of

200 anterior with right hand, and

100 to the left with left hand.

37. S.S.

21

FContusion on turns.

38. T.L.

18

FPoor balance, Poor hael and toe

walking. Only fair tandem gait.

Pea planus. Head tilt to right with

cervical kyphosis. 300 verticalo-

meter error anterior when measured

with right, left, and both hands.

Head rocking. Tense posture.

Therapy

BA

Mobility

BA

IQ

Psych.

III

III

Improvement

Score

23+

FF

68

560

1639

21 - A

34-

PF

75

158

1200

7 - C

4+

4+

FF

92

559

1630

9 - C

34-

pF

85

260

1620

14 - A

No. Init. Age Sex

Ortho-Neuro-Findings

39. R.B.

21

MTight hamstrings. Mild dorsal

kyphosis. Only fair balance.

Poor tandem gait. Mild pes

planus. Veers to right. Fair

spatial localization and

storeognosis. 200 left verticalo-

meter error when measured with

left hand. Poor body concepts.

40. N.C.

19

FObese. Mild left verticalometer

error with right and left hands.

Poor graphesthesia for a triangle

and square. Only fair spatlal

localization. Poor body concepts.

41. J.Z.

26

MOnly fair sitting posture. Poor

tandem gait. CSP. Rigid gait. Pes

planus. Veers to left. Poor

graphesthesia: RYperreflexia with

slight ankle clonus. Questionable

two point discrimination. Bask

leaning. Slightly athetoid. Slight

circumduction gait. Read rocking.

Poor body concepts.

42. R.W.

23

MTight hamstrings. Outflare gait.

Pea planus. Poor graphesthesia.Poor

body concepts. Poor hand coordi-

nation.

43. T.M.

19

FCSP. Poor standing posture. Left

verticalometer deviation of 100

with right, left and both hands.

Spastic diplegia. Mildscollosis.

Equinus feet. Ryperreflexia with

ankle clonue,right worse than left.

Tension adduction of hips with

mild positive Babinski responses.

Poor body concepts. Poor balance.

Poor hand coordination.

Therapy

BA

Mobility

BA

IQ

Psych.

III

III

Improvement

Score

33

PF

95

060

1700

12 - A

3+

4-

PP

84

060

1600

8 - c

3-

3+

PP

58

154

1600

5 - c

33+

PP

97

143

15o°

16 - A

23-

PP

70

36o

160°

15 - A

No. Init. Age Sem

Ortho-Neuro-Findings

44. T.U.

18

NMild thoracic kyphosis with tight

hamstrings. Anterior rocking.

Slight veering to right. Hyper-

reflex's. Poor hand coordination.

45. B.S.

20

FMild kyphosis. Vertioalometer

deviation of 200 posterior with

right, left and both hands.Tense

posture with forward head droop.

Poor tandem gait. Pes

Poor spatial localization and

poor position sense. Poor two

point discrimination. Poor bey

concepts.

Therapy

BNobility

IQ

III

III

Improvement

Score

34-

_EA

PG

73

157

1540

6 - c

34-

PG

109

160

1700

20 - A

15 10 5

0

IMPROVENNNT IN POSTURE THERAPY

CHART 1

\\\\\,

Student who began at the It mime level or above

15

Group B- 8

(tromp A- 20

S1/3

2/3

Improvement

11

1/3

15

30 5 0

0renp C- 17

lka

1/3

2/3

Improvement

11

1/3

10 5 0

15

10

5 0

S1/3

fij

Improvement

11

1/3

2/3

Improvement

I1

20

15

10

20

15

10

5

b

1XPROVIMENT IN MOBILITY

Students lib* reasiasd at POOR 1on1.

Group 1- 20

1 2

Gamma C.. 1T

6i

20

15

10

5

0

20

15

10

5

0

CHART 2

(hasp B- 8

I3 1

Total

3

60

E IIIV

HO

5I

Ca

t0

cos

St

-0 thus0

S11

Ea

t0

-1Fir117711F

gt .or dame

I AN

L 'M

IN

SOT

SE

501St

MI20 Ea

(An) t

C

09 r4 SS

liS ir4 oil

a 44 Sa Male A

ft

a

'smog N

unn

I

47 1.111/HO

0SOt

St

Ca

I

IT'St -0 tow

Ca

I

II £'H

UN

0S0SSt

ca

zm

aneo

g-g dneag

s.1.3

SOI

St

St -3 &taw

C8

01ST

I211rav8

rD0

.,-

III 8988 'WM

SOt

St

a

1 1/3

1 '/3 v3

INPR

OV

IEN

NT

IN

PO

BN

INE

TIM

M &

IN

PRO

VIM

EN

T I

Nno

rcur

r

No improvement in nobility

05

10

Impr

ovem

ent m

ore

.f 2 in nobility

42/

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11.

1111

11

CH

AR

T 6

Impr

ovem

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sore

of1 in nobility

05

10

Students mho began at Is mime

leve

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abov

e

65

Summary

Posture in the blind has been investigated. Several of itsdeterminants have been utilized in the diagnosis and treat-ment of malposture. Improvement in postural ability has beenfound to correlate with improvement in mobility skills. Forthose dealing with the vocational and rehabilitation problemsof the blind (mobility instructors, teachers of the blind,vocational and rehabilitation counselors, etc.) some knowledgeof these matters is essential. No blind rehabilitation programis complete unless it considers the postural problems of itsclients. Many of these problems are peculiar to the state ofblindness, particularly those present in the congenitally blind.Such things as overactive basic postural reflex mechanisms,lack of vertical sense, and poor body image contribute to thestate of malposture in the blind. Occasionally, a simpleorthopaedic problem, easily corrected, can play a significantrole in an individual's rehabilitation potential. It seemsobvious that orthopaedic, physiatric and physical therapyskills are necessary in the total rehabilitation of the blindstudent. Treatment must include a variety of therapeutictechniques, some newly described, tailored to meet the spe-cific postural needs of each subject.

The practical significance of this study is that the methodsherein described can be applied to any blind student with areasonable assurance that his posture will be improved, hismobility skill increased, and his rehabilitation thus en-hanced. It is hoped that the theory elaborated, as well asthe diagnostic, treatment and evaluative techniques describedwill add to the researoh armamentarium of other workers inthis field.

66

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3. Barlow, W., Psychosomatic problems in postural re-educa-tion, Lancet, 21659,1955.

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67

17. Christman, E.H. & Kupfer, C.: Propriooeption in exta-ocular muscle, Arch. Ophth. (Chicago),691824,1963.

18. Cohen, L.A.: Role of eye and neck proprioceptive mechan-isms in body orientation and motor coordination, J.Neurophysiol. 2411, 1961.

19. Cohen, W.& Tepas, D.: Temporal factors in the perceptionof verticality, Am.J. Psych. 71:760, 1958.

20. Ccle, N.J. & Taboroff, L.H.: The psychological problemsof the congenitally blind child; workshop, 1954, Am.J.Orthopsychiat. 25:627, 1955.

21. Critchley, M.: Tactile thought, with special reference toblind: president's address, Brain 76:19, 1953.Also in:Proc. Roy. Soo.Med. 46:27, 1953.

22. Crowder, C.H.J.1 Posture and body mechanics,J. Osteo-path.69117, 1962.

23. Curran, C.R.& Lane, &L.: On the relations among somefactors that contribute to estimates of verticality,J.Exp. Psych. 64:295, 1962.

24. Epstein, L.: The relationship of certain aspects of thebody image to the perception of the upright, New YorkUniversity, 1958. Abs.: Dissert. Abs. 22:639,1961.

25. vcn Fieandt, K.: Form perception and modelling of pa-tients without sight, Conlin. Psychiat. 2:205,1959.

26. Fisher, S.:A further appraisal of the body boundary con-cept. J. Consult. Psych. 27:62,1963.

27. Fleishman, E.Ast Perception of body position in theabsence of visual cues, J.Exp.Psych. 46:261,1953.

28. Fukuda, T.: Studies on human dynamic postures from theviewpoint of postural reflexes, Acta Oto-laryngol.Suppl. 161, 1961.

29. Gesell, A.L.: The tonic neck reflex in the human infant,J. Pediat. 13:455,1938.

30. Gesell, A.L.: The embryology of behavior, New York,Harper & Bros., 1945.

31. Goff, C.W.: Posture in children, Cline Orthop.1:66,1953.

32. Grose, F.: The role of set in perception of the upright,J. Personality,27:95,1959.

74

68

33. Halpern, L.: Optics function and postural attitude,Neurology, 41831,1954.

34, Hauser, E. & Elston, M.: Exercises for backache due tofunctional deoompensation, The physiotherapy Review 17:#2,47, 1937.

35. Head, H. & Holmes, G.: Sensory disturbances from cerebrallesions, Brain 34:102, 1911.

36. Hellebrandt, P.A., Houtz, S,J., Partridge, M.J.& Walters,C.E,s Tonic neck reflexes in exercises of stress in man,Am.J. Phys. Med. 35:144,1956.

37. Hellebrandt, P.A., Sohade, M. & Carns, M.L.:Methods ofevoking the tonics neck reflexes in normal human subjects,Am. J.Phys. Med. 4100,1962.

38. Hippocrates: Ancient medioine and other treatises,Bk.23,Chapter 8 (Cited by Bettman, 0.L.: A pictorial history ofmedioine, Springfield, Charles C.Thomas, 1956).

39. Hoover, R.E,s Orientation and travel technique for theblind, Am. Ass. Workers for the Blind, p,27,1947,

40. Howorth, Bei Dynamic posture in relation to the feet,Clin. Orthop. 16:74, 1960.

41. Hunter, W.F.: An exploratory analysis of space perceptionin congenitally blind and sighted individuals, MichiganState University, 1960. Abs.: Dissert. Abs.: 21:(11)3530,1961.

42. Hunter, W.F.: An analysis of space perception in congeni-tally blind and sighted individuals, Percept.Motor Skills15:754, 1962.

43, Jones, F.P. et al: An experimental study of the effect ofhead balance on patterns of posture and movement in man,J. Psych. 47:247,1959.

44. Jones, F.P. & Narva, Moo Interrupted light photography torecord the effect in the poise of the head upon patternsof movement and posture in man, J. Psych. 40:125,1955.

45. Jones,F.P. & O'Connell, Dal': Posture as a function oftime, J. Psych. 46:287, 1958.

46. Kesareva, E.P.: Tonic reflexes in man: communication III.Tonto cervical reflexes in healthy adults and the influenceof unstable position on these reflexes, Bull. Exper.Biol.& Med. 46:766,1958.

7J

69

47. Kiernander, B.& Barlow, W.:Discussion on postural re-education; a critical examination of methods, Proc.Roy.Soc. Med. (Sect. Phys. Med.) 49:667,1956.

48. Kitamura, S.: Tendency to reduction in size of auto-scopio image and visual body image, Tohoku Psych.Polia19:17,1960. Abe.: Psych. Abs. 35:4990,1961.

49. Kuhns, J.G.1 Diseases of posture, Clin. Orthop. 25164,1962.

50. Landis, M.B.: Correction of body carriage and posturedefects through a physical education class, The TeachersForum, Spet. 1937.

51. Latimer, RA.: Utilization of tonic neck and labyrinthinereflexes for facilitation of work output,Phys. Therap.Rev. 33: 237,1953.

52. Lowenfeld, B.: Effects of blindness on the cognitivefunctions of children, Nervous Child 7145,1948.

53 Lowenfeld, G.: Physical education - a "must" for blindpupils, Outlook for the Blind, 39:128,1945.

54. Lund, F.11,1 Physical asymmetries and disorientation, Am.J. Psych. 42:51,1930.

55. Mac Donald, P.: Instinct and functioning in health anddisease, Brit. M.J.21 1221, 1926.

56, Magnus, R.: Korperstellung, Berl.,Julius Springer,1924.(Translation of Chapter III by Brfinnstrom, S., Phys.Therap. Rev. 33:281,1953).

57. Magnus, R. Animal posture: Croonian lecture, Proc.Roy.Soc. Lond.981339,1925

58. Mann, C.V., Berthelot - Berry, N.H. & Dauterive, H.J.,Jr.:The perception of the vertical. I. Visual and non-labyrinthine cues, J. Exp. Psych. 39:538,1949.

59. Mann, C.W. & Passey, G.E.s The perception of the vertical.V. Adjustment to the postural vertical as a function ofthe magnitude of postural tilt and duration of exposure,J. Exp. Psych. 41:108,1951.

60. Martin, J.P.: The basal ganglia and locomotion, Ann.Roy.Coll. Surg. Eng. 32:219,1963.

61, Mathieu, Jacques. Cited by Bettman, 0.L.: A pictorialhistory of medicine, Springfield, Charles C. Thomas, 1956.

70

62. McFarland, J.H., Wapner, S.& Werner, H.: Relation betweenperceived location of objects and perceived location ofone's own body, Percept. Motor Skills 15:331, 1962.

63, McFarland, J.H., Werner, H. & Wapner, S.: The effect ofpostural factors on the distribution of tactual sensitivityand the organization of tactual-kinesthetic space, J.Exp.Psych. 63: 148, 1962.

64. MoMorris, R.O.: Faulty posture, Pediat.Clin. N.Am. 8:213,1961.

65. Miche555,le, A.A.: Posture and physical fitness, Milit, Med.127: 1962.

66. Moltke, E. & Skouby, A.P.: The influence of tonic neckreflexes on the activity of some muscles of the trunk inpatients with asthma and emphysema, Acta med. scand. 173:29, 1963.

67. Mountoastle, V.B. & Powell, T.P.: Central nervous mechan-isms subserving position sense and kinesthesia, Bull.Johns Hopkins Hosp. 1051173,1959,

68. Miller, K.: Beobachtungen zur Psychomotorik blinder Kinder,Klin. Monat. Augenheilk.1341213,1959.

69. O'Neill, H.: A study of the attitudinal reflexes of Magnusand de Kleijn in thalamic Llano Arch.Otolaryng. 431243,1946.

70. Partridge, M.J.: Electromyographio demonstration of faci-litation, Phys. Terhap. Rev. 34:227, 1954,

71. Passey, G.E. & Guedry, F.E.: The perception of the verti-cal. II. Adaptation in four planes, J.Exp. Psych. 39:700,1949.

72. Pearson, B.G. & Hauty, Gass Adaptive processes determin-ing proprioceptive perception of verticality, J. Exp.PsY011.571367.1959.

73. Ramazzini, Bernardino. Cited by Bettman, Mi.: A pictorialhistory of medicine, Springfield, Charles C. Thomas,1956.

74. Rothman, Ea.: Some aspects of the relationship betweenperception and motility in children, Genet,Psych.Monogr.631 67,1961,

75. Rushworth, G.: On postural and righting reflexes,CerebralPalsy Bull. 3:535,1961.

76. Sandstrom, C.I.: A note on the Aubert phenomenon, J.Exp.Psych.481209,1954,

7?

71

77. Sherrington, C.S. The integrative action of the nervoussystem, New York, C. Soribner's Sons, 1906.

78. Sherrington, C.S,, On the proprioceptive system, espe-cially in its reflex aspect, Brain 291467,1906,

79. Sideman, S. & Bartges, K.M.1 Adhesive oapsulitis of theshoulder joint, J. Int. Coll. Surg, 391252,1963.

80, Siegel, I.M. & Turner, M.1 Postural training for theblind, Physical Therapy, Journal of the American PhysioalTherapy Association 45sNo.7s683, July,1965,

81. Smith, K.U.: The geometry of human motion and its neuralfoundations. I. Perceptual and motor adaptation to dis-placed vision. Am. J. Phys. Med. 40171,1961.

82. Solley, C.M.: Reduction of error with practice in per-ception of the postural vertical, J. Exp. Psyoh. 521329,1956.

83. Solley, C.M.: Influenoe of head tilt, body tilt, andpractice on reduotion of error in perception of thepostural vertical, J. Gen. Psych.62169,1960.

84. Strnad, S.* Pretence and causes of faulty body postureand spinal disorders in youths with vision disorders,Cesk.oftal. 19,139,1963.

85, Swinerton, L.D.s Treatment of some of the postural defectsand habit motions common among the blind, Indian M. Rec.,Caloutta, 37,121,1917. Also in, Boston M. & S.J. 176,803,1917.

86. Swinerton, L.D,, Posture training for blind ohildren,TheTeachers Forum, p.10, Jan.1930.

87, Waffa, J., Fencing as an aid to the rehabilitation ofblind persons, Outlook for the Blind, 57sNo.2,1963,

88. Walshe, F.M.R., On certain tonics or postural reflexes inhemiplegia, with special referenoe to the so-called"associated movements", Brain 4611,1923.

89, Wapner, S. & Werner, H., Experiments on sensory-tonic fieldtheory of perceptions V. Effect of body status on the kines-thetio perception of verticality, J,Exp.Psych. 44,126.1952.

90, Wapner, S., Werner, H. & Morant, Rase Experiments onsensory-tonio field theory of perception. III. Effect ofbody rotation on the visual perception of verticality, J.Exp. Psych. 421 351, 1951.

7a

72

91. Wells, H.S.8 The demonstration of tonic neck and laby-rinthine reflexes and positive heliotropic responses innormal human subjects, Science 99836,1944.

92. Werner, His Motion and motion perceptions a study ofvicarious functioning, J. Psych. 198317,1945.

93. Werner, H. Wapner, S. & Chandler, K.A.8Experiments onsensory-tonic field theory of perception. II. Effect ofsupported and unsupported tilt of the body on the visualperception of verticality, J. Exp. Psych, 428346,1951.

94. Wight, B.W. et alp Perception of lower limb position andextension in physically disabled children, Percept.MotorSkills 1,1667,1963.

95. Witkin, H.A.8 The perception of the upright,Scient.Am.200851,1959.

96. Witkin, H.A.8 Perception of body position and of the po-sition of the visual field, Psych. Monogr.63010.7,1949(issue 302).

97. Witkin, H.A. & Asch, S.E.8 Studies in space orientation.III. Perception of the upright in the absence of avisual field, J. Exp. Psych. 388603,1948.

98. Worchel, P.a Space perception and orientation in theblind, Wash., Am. Psych. Ass. 658 No.15,issue 332,1952.

99. Yamshon, Machek, 0. & Covalt, D.A.1 The tonic neckreflex in the hemiplegict an objective study of itstherapeutic implication, Arch. Phys, Med. 308706,1949.

APPENDICES,

80

CFS-201

1/64

Nam

ECRIBIT 1

STATE OF ILLINOISDEPARTMENT OF CHILDREN AND FAMILY SERVICES

COMMUNITY SERVICES FOR THE VISUALLY HANDICAPPED

FACE SHEET

1

Birth Date I Birth Place

Cross References (Alias)

Date Referred. Referred. By

ADDAMS=

Date 8trett Number or R.F.D. and City County Telephone Teacher

RBIATIVES AND 'n INTIMESTID PERMS

Jane Address Relationship Telephone

Other Agency Contacts

Moments

rafornation Obtedned TV: Visit Telephone

Other (Specify) Date

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CFS 202(Rev. 8-66)

STATE OF ILLINOISDEiCA 2136414T OF CHILDREN AND FAMILY SERVICES

ILLINOIS VISUALLY HANDICAPPED INSTITUTE

APPLICATION FOR ADMISSION

Name: DateLast First Middle

EICHIBIT 2

Address: TelephoneNumber Street

City County State Zip Code

Date of Birth: Sex Marital Status

Social Security No:

Family Doctor:

Address: TelephoneNumber Street

City State

Hospital Insurance:

Meeical Policy No.Name of Company

Surgical Policy No.Name of Company

I do hereby apply for admission to the Illinois Visually Handicapped Institute andagree to undergo a two-week evaluation which includes a. medical examination. TheInstitute has permission to release information in my file for the purpose of developinga rehabilitation plan for me.

Signed:

NOBILITY EVALCATTOR EXHIBIT 3

STUDENT DATE LISTELICTOR

I Visual Acuity

A. Rlsidual Vision Amount None

B. Prognosis Good Poor Unknown

C. Blindness Occured Birth Age

D. Cauoe

II. Use of cane

A. Carries cane Identification Protection

B. Students needs cane Not At All

C. Previous Mobility Instruction None Some

Where

How Long

D. Student Travels Independently Yes No

R. Describe technique(self-taught, effective, etc.)

S. Student's feelings about using cane

'4III. Orientation

A. Ability to turn on commandCorrect Incorrect

1. 90 right turn2. 90 left turn3. About-face (180 )4. Complete turn (360)

B. Ability to make compus point turns (Return student to North each time)Correct Incorrect

1. Tura to last2. Turn to West3. Turn to South

84

Exhibit 3 cont'd.C. Continual turn, (Soniq with student facing North and faces student

in correct position Is turn was 'incorrect;

1. Face South

2. Vacs last

3. Fate West

4. Pace South

5. Pace Vest

6. Two North

Incorrect Correct

D. Awareness of turns (walk 'minors with student on arm, begin withbacks to the wall and inform student be is facing North)

Ask student following questions: )41. Now many directions traveled4. Roo may turns In what directions3. What direction on coalition of pattern4. Able to reproduce pattern on board Yes No

.77.1, Now many directions travelor2. Nov many turns in what directions3. What directioorM114en comletion of pattern4. Able to reproduce pattern on board Yes SoComments

S. Memory, ability to reverse, direction, judge distance, and with astraight lins(repeat following directions as often as necessarybefore student begins):Walk straight 10 feet, turn right and walk S feet, turn left andwalk 5 feet.

1. Accurate in all area2. Inaccurate in following areas (describe):

a, Ismanbering directions in proper orderb. Judging distancec. Walking straight lined. In direction of turn In degree of turnReverse direction to return to starting point

1. Accurate in all areas

8i

Cont. Exhibit 3 contd.

2. Inaccurate (describe): --------------------

Comments (possible reason for erro :s, etc.)

IV Stairs

A. Fearful stairs Yes No

B. Uses cane on stains Yes No

C. Safe on stairs Yes No

V Cdit and Posture

A. Obvious postural problems exist Yes

Describe:

B. Student Has a normal gait Yes No

Describe:

VI Recommendations;

-3-

86

EXIIIII/T 4

EXPLANATION OF RATING SCALE

SUPERIOR--Student can travel independently and safely anywhere, evenusing public transportation, remains oriented and needs no furtherinstruction in the area of orientation and mobility.

EXCELLENT--Student can travel independently and safely anywhere, even usingpublic transportation, remains oriented, but may need some familiarizationtrips when required to travel in an unfamiliar area.

GOOD -- Student cant travel intiependently and safely in familiar areas, butmay need more instruction in ihe use of public transportation and in travelin unfamiliar surroundings. He may occasionally become disoriented butshould, in most cases, be able to reorient self.

FAIR--Student does not yet travel independently. He will need much moreformal instruction and practice in proper cane technique, concept formation,use of clues, and utilization of remaining senses. He probably haspotential for reaching a "Good" rating.

POOR--Student does not travel independently. He has problems with oneor more or a combination of several of the following: concept formation,use of clues, proper cane technique, use of remaining senses, judgment,comprehension, attention span, motivation, or physical limitations.The student will probably never become an independent traveler.

81'

lams:

Diagmisis:

EXHIBITS

ORZIOPNDW EVALUATION

Age: Rex: DOW

Congenital Utal,.jartia/....progressive...Hoaring_

Handedness: Left Right LO Foot

Problem (why at institute!):

Past history of orthopaedic problems:

imminatim:

Sitting postureStanding postureRombergStanding so each foot aloneHeel and too walkingTandem gaitGait/bola:umlackFeetVeeringJoint range of motionComtractures or tension ticksWinger to nose testDysdiadokokinosiaSpatial localisationb/adduction fingersSterognosisPosition senseOraphesthesiaWeighing perceptionSensationReflexes2 point atscriminationMammal dexterityVibratory sense

Wisc.

Diagnosis:

lecomendation2

Rend P L R

a

L

Seth. I

Yollou-up Noma.:Date

86

VERTICALOHETER

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EXHIBIT 6

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Exhibit 7

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EXHIBIT 8

PKISICAL THERAPT

Ihme Age Date

Dins: :olds AMMO.

Hip abduction_Hip flexion_Knee flexion.Pee pianosOut teeing....In-toeing_...

Bead dropMead tiltIhealder slumpLipper extremity rigidity_,,Torso shift

Dorsal typhosisBooliesisLordosieAbdominal pretsberammt...Pelvic tilt

Poor body concepts:

Poor pit patters:Vide based Hesitant Propulsive Veering_ Other

Peer orientation:

Cestractures--limitat les of motions

Mum ler meekness:

Treatment:iscorcises:

Passive & stretching exercisesActive 6 resistive exercisesBalance exercisesPostural exercisesDelexatim exorciseskennels exercises

Gait training_Crawling..TreadmillSlantboark.Balance bsusPulley

",..11=111=1=a

Body concept training:

Orient. within:11_,Orient. with fan.Menneentn..2WanalTrampoline..Applimmmuk...

Iliseellameses:

Progress Metes:

Date

91

ENID IT 9

TACTILE DISCRIMINATION TESTS

9

la

lb

lc

ld

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PORN CONCEPTS

INSTRUCTION AND TALLY

Here is a piece of plastic - can you tellme what shape it is?What shape is this one?What shape is this one?What shape is this one?

Here is a piece of wood with a shape on it.Can you tell me what shape this is?What shape this is?What shape this is?What shape this is?

Same as above - figure groundWhat shape is this?What shape is this?What shape is this?

Same as above - sand paper insideWhat shape is this?What shape is this?What shape is this?

Same as above - sandpaper outsideWhat shape is this?What shape is this?What shape is this?

EXHIBIT 10

ScorePre-Post

Training: Present each form in all media -allowing student to examine tactually while E identifies eachverbally.

2a Through e repeat of phase one - same sequences.

3 Place all forme in front of student in mixed order.Now I want you to sort these out.Put all the Same Shapes togetherMake four pilesNumber correct 4_0 CI

Is ton

1800

170

160

£50

140

130

120

110

100

90

100

110

120

130

140

150

160

170

180

TALLY SHEET TEST OF PARALLELITY

S me Same (parallel)D me Different (non-parallel)

94p

Exhibit 11

EXHIBIT 12

PARALLELITY INSTRUCTIONS

Here are two pieces of wood. Run your index fingers along the topedges. You'll notice that they are parallel, that is, they go inexactly the same direction all the way to the end. Now, the pieceof wood on your right can be moved and I'm going to move it todifferent positions - then I'll ask you whether the two pieces areparallel or not. You may run your fingers along the pieces twotimes, back and forth, then tell me whether they're going in thesame direction all the way to the end, that is, whether they'reparallel or not.

Run four trials, alternating ascending and descending series, scoringS or D - same or different.

4

ICIETITT 13

TURNING

'INSTRUCTIONS AND TALLY

Let student examine apparatus, then introdude all 8 positions from azero point alternating right and left turns

Now I'll ask ydu to hold the pen and turn it (left or right).Always begin at zero poink for each trial. Use following sequence.

Number of Degree of S's Turn.

1. Full Turn left (all the way around) 0 - 360°

2. Quarter way right (0-90°)

3. Half-way around right (0 -180 °)

4. Three-Quarters of the way around left (0-270°)

5. Three-Quarters of the way around right (0-270°)

6. Full turn right (0-360°)

7. Quarter way left (0-90°)

8. Halfway around left (0-1804))

96

EXHIBIT 14

MONTESSORI EQUIPMENT

9 I'

EXHIBIT 15

LIFE SIZE MANNEQUIN

ii

9 0-

11

"WIND TUNNEL"

Mr

EXHIBIT 16

ILLINOIS VISUALLY HANDICAPPED insTrwrE

POSTURAL EXERCISES

SERIES I,

Emus 17

Dr. I. M. Siegel

Exorcise I.

A. Correct standing position (abdominal muscles and posterior hipmuscles tightened).

B. Full inspiration.C. Raise arms forward over head, (elbows, wrists and fingers extended),

very slowly.D. Stretch arm upward at top of arm movement.E. Return arms to starting position in the same arc of movement, same

rhythm and resistance as in C.F. Exhale.

Exercise,II.Same as in I, except that arms are raised to the sides. The palms areturned up upon reaching shoulder level so that the palms face each otherabove the head at the top of the movement.

Exercise III.

Same as in I, except that the hands are placed behind the head. Theelbows are then brought in to the center, and returned to the sides.

Exercise IV.Mteralbetrtandef_ith.A. Correct standing position, hands may be placed on.hips.B. Full inspiration.C. Bend the body to the side (all movement takes place at the waist).D. Return to upright position.E. Exhale.

Repeat to opposite side.

Exercise V.Forward bending o trunk.

A. Correct standing position, hands may be placed on hips.B. Bend trunk at the hip joints, maintaining straight position of the

back and head.C. Return to correct position.D. Exhale.

Caution: Bend only as far as correct position of the back can be heldwithout pain or strain.

Exercise VI.Balance Series.

A. Correct standing position, hands may be placed on hips.B. Full inspiration.

1 0

2

Exhibit 17 oont scl.

POSTURAL EXERCISES Dr. I. M. Siegel

C. Shift weight onto one foot, raise opposite leg with knee straight.At first one may only be able to raise the leg a few inches withoutlosing balance. As strength and co-ordination improve, this willgradually increase.

D. Return leg to starting position.E. Exhale.

This exercise is repeated, bringing right and left legs forward; thenright and left legs sideward; and finally right and left legs back-ward. Each time the same procedure is followed as given in theexample above.

SERIES II

Shoulder Motion - with arms at sides.

Exercise I.Raise tips of shoulders toward ears, and then relax.

Exercise II.

Pull shoulders back (so shoulder blades come together in center of back),and then forward. Relax to starting position.

Exercise III.

Bring shoulders and forward (at same time) and then down and back.Repeat each exercise 5 - 10 times slowly.

Additional Exercises1. Standing and sitting on floor, with knees straight, touch fingers to

toes.

2. Bend head forward so chin touches chest, and then tilt head backward.3. Turn head to the right and then to the left, keeping rest of body still.

101

FELT AND STOCKINETTE COLLAR

10

EXHIBIT 18

'44

LIGHT SHOULDER SPLINT - FRONT

Exhibit 19

TRAMPOLINE AND HARNESS WITH "SPOTTERS"

EXHIBIT 20

EXHIBIT 21

10

EXHIBIT 22

RATING SCALE - PHYSICAL THERAPY

Very poor posture with many postural defects. Very poor balance with in-ability to stand alone on one foot. Inadequate gait pattern. Walks alone withconsiderable effort. Considerable muscle weakness or limitation of range of motionin joints. Very poor body concept with limited knowledge of body parts and awarenessof limb positions. Very poor orientation - unable to orient in strange surroundings.

2.

Poor posture with several postural defects or marked tenseness. Poor balance

with ability to stand on one foot only momentarily. Poor gait pattern with more thanbne major gait problem (i.e. outtoeing, shuffling, marked veering, etc.). Muscle

weakness of trunk muscles and at least one other body area. Some limitation of rangeof motion. Poor body concept with confusion concerning location and relationship of

body parts. Poor orientation with unsureness of shapes and difficulty in strange sur-roundings.

3.

Fair posture with one or more postural defects and/or some tenseness. Fairbalance with ability to stand on one foot for a short time (5-10 seconds). Fair gait patternwith only one major gait problem. Some muscle weakness, primarily in the trunk muscles.Some limitation of range of motion, primarily in the heel cords, hamstrings or pectorals.Fair body concept with confusion with more eomplicated joint motions and some relation-ships of body parts. Fair orientation with some initial difficulty orienting but ability toorient after several attempts.

4.

Acceptable posture with only minor postural defects or ticks. Adequate

balance. Able to stand on one foot at least ten to fifteen seconds. Acceptable gaitpattern with only minor defects (i.e. some veering or slight outtoeing, etc.). Normalmuscle strength and normal range of motion. Adequate body concept with adequateorientation and only minor difficulty in strange surroundings.

5.

Good posture with no noticeable postural defects or ticks. Good balancewith ability to stand on one foot without difficulty and good gait pattern with no gaitdefects. Normal muscle strength determined by manual testing and full range of motionof all joints. Good body concept with awareness of joint motions and body position andknowledge of body relationships. Good orientation with ability to rwecute turns anddetermine shapes and dimensions in strange surroundings.

100

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EXHIBIT 23

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EXHIBIT 27

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EXHIBIT 29

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