Exeley Inc.

de Haseth Meddens, Laura

International Journal of Orientation & Mobility • Volume 1, Number 1, 2008 79
Opening Eyes and Opening Doors
Laura de Haseth Meddens
Imagine yourself walking in bright tropi-
cal sunlight from your car into a Doctor’s 
laser clinic, and leaving a short time later 
surrounded by “blurry mist.” This occurred 
because of someone else’s self-admitted 
“stupid mistake” in not referring me to a 
qualifi ed specialist with adequate equipment 
in the Netherlands or the United States.
This happened in Curaçao which lies 
about 35 miles off the northern coast of Ven-
ezuela in the southern Caribbean. It has been 
a part of the Netherlands Antilles, or what 
was formerly called the Dutch West Indies. I 
was born there, and grew up in England and 
the Netherlands.
I returned to the island to complete my 
university studies, which, needless to say, 
were interrupted by this devastating turn of 
events. After going through the various phas-
es of shock, fear, grieving and acceptance, I 
was determined not to crawl away and hide 
in a corner. I did, however, come face to face 
with issues of mobility and orientation that 
were somewhat unique and compounded by 
having lost the majority of my eyesight in my 
late twenties. I also lived on a tropical island 
where the living and treatment infrastructure 
differed greatly from other countries.
As part of trying to achieve some orienta-
tion in a new life that felt very disoriented, 
the Blind Institute gave me a cane. Unfortu-
nately the cane was not successful because, 
as people at The Seeing Eye later told me, it 
was too short. Subsequently, the Blind In-
stitute employed a mobility facilitator who 
informed me about the possibilities a guide 
dog could offer.
Curaçao is a part of the Kingdom of the 
Netherlands, so I initially tried to apply for a 
guide dog from Holland. Unfortunately this 
was disallowed because I wasn’t insured in 
Holland. I then learned about the wonder-
ful work of The Seeing Eye Incorporated in 
Morristown, New Jersey, USA in assisting 
the vision impaired and blind new opportu-
nities for personal growth, increased mobil-
ity and a better quality of life.
After successfully completing the inter-
view process, I eventually travelled to Mor-
ristown, and returned home with my guide 
dog Wagner. It was another life-changing 
experience. You can read more details of this 
experience in “The Seeing Eye and Beyond” 
in the Articles section of my website: www.
LauraAndWagner.com
I believe the issues of orientation and mo-
bility are quite different for someone born 
blind than they are for someone who loses 
their sight later in life. For those in the for-
mer category, please forgive any presump-
tions that you don’t feel are accurate.
I think when you are blind from birth, or 
lose your sight as a child, you become more 
psychologically conditioned to initially ac-
cept being reliant on others with O&M until 
you become more independent. It is more 
diffi cult being confronted with a new reality 
of sensory or mobility loss after living a life 
of independence and self-reliance.
In my case, I suddenly became complete-
ly dependent on others around me for almost 
International Journal of Orientation & Mobility • Volume 1, Number 1, 200880
everything I had previously been able to do 
myself. Over time, I regained some of my 
former independence once I was able to ori-
ent myself to my immediate surroundings.
You tend to build a cocoon of familiarity 
around yourself as you try to adapt to the 
shifting “balance control” in your brain that 
brings more focus to the sounds, scents and 
tactile feelings of your new world, that sup-
plements the vision loss. The cocoon in this 
case was my house. Within that cocoon, the 
familiarity was gradually achieved through 
repetition and order. Outside the cocoon was 
another matter, especially in a place where 
order can be diffi cult to achieve, regardless 
of repetition. I became completely depen-
dent on loved ones and friends, until more 
options opened up with the arrival of Wag-
ner that enabled me to leave the house when 
I wanted to.
The complex urban infrastructure of Mor-
ristown, was in stark contrast to the island 
of Curaçao. When I brought Wagner home 
to Curaçao, I lived in a house in one of the 
nicest neighborhoods on the island that ac-
tually had sidewalks. I was able to build an 
expanding walking routine that included a 
vigorous trek through hills surrounding nat-
ural salt lakes. 
However, outside of our neighbourhood, 
Wagner and I were not greeted with open 
arms. There was a lack of sidewalks in a lot 
of areas, and it wasn’t dog friendly. Dogs 
were either guard dogs, or feral dogs, with 
some being quite dangerous when encoun-
tered on walks. It became quite an adjust-
ment for the two of us. I would try to travel 
with Wagner into the city to work on pedes-
trian crossings, sidewalks and traffi c lights. 
Sometimes I felt island life was too “lazy’ 
for a dog as intelligent and highly trained as 
Wagner. I would often think “beam me up 
Scotty, is there any intelligent life around 
here?” But Wagner did love the freedom of 
running along the beach and splashing in the 
warm Caribbean Sea.
While the island itself is very beautiful, 
and most of the people are very friendly, it 
is a lagging culture when it comes to how 
people with an impairment or disability are 
treated. Sometimes people with disabilities 
are treated in a hostile way. There is a culture 
of shame within families where a member has 
a disability. I recently learned about a 12 year 
old blind boy who had never been to school 
or travelled outside his house. Another wom-
an told me of her mother feeling ashamed of 
her vision loss late in life because it made 
her dependent on her loved ones. With this 
particular feeling I could relate.
If an attempt is made to reassert some 
independence through the use of a guide or 
assistance dog, you have to fi ght for your 
rights and freedom because, in many cases, 
you are not allowed to enter certain places. 
In some cases, you also have to overcome 
very narrow-minded and discriminatory 
perceptions, including shopkeepers shout-
ing at you to “get out!” These attitudes are 
quite ironic, in a place that is very sensitive 
about the former discriminatory treatment of 
slaves.
Something had to change. After a friend 
designed a website for me as an online
base for a documentary he wanted to make 
about my experiences, I felt we could take 
it to the next level. This resulted in the 
development of ‘The Laura And Wagner 
Foundation’ to help liberate disabled people 
from that “curtain of shame.” The Founda-
tion would assist disabled people to gain 
the tools that helped me to work toward the 
International Journal of Orientation & Mobility • Volume 1, Number 1, 2008 81
goals I had before I lost my sight. I was able 
to access a computer with text reading/writ-
ing software, as well as a Daisy player CD 
reader which enabled me to continue my 
studies in psychology.
I wanted the Foundation to be an advo-
cate for people who don’t see, hear or walk 
as well as the rest of the community. The 
Foundation’s goals include assisting people 
with a disability to achieve increased mo-
bility through the use of a guide dog or as-
sistance dog, and leading a campaign for an 
access law that would allow anyone who 
uses one of these service animals to access 
all environments. I also want the Foundation 
to be a resource for people who lose their 
vision later in life whose unique needs and 
challenges are very different from those 
congenitally blind. Initially, the established 
organisation for the blind on the island was 
more equipped to help the congenitally 
blind, and was overwhelmed and ineffec-
tive in helping those, like me, who lost their 
vision later in life. The usual experience of 
sitting with other people with the same dis-
ability in well-meant communal and social 
activities isn’t always comfortable for some-
one who’s lived a life of great independence 
and self-reliance.
Another goal of the Foundation is to 
achieve a 555 helpline information directory 
for people with disabilities on the island. 
Conveniently, the ‘5’ on any keypad has an 
orienting raised dot for blind and vision im-
paired people. 
The Foundation is also producing a
global television documentary that will 
chronicle O&M issues around the world, 
such as the story of Paralympic gold-medal-
ist Ping Yali who encountered access issues 
with China’s fi rst guide dog, “Lucky” in 
Beijing. The documentary will also feature 
Dan Kish from the US who, although blind 
from birth, fi nished his psychology degree. 
Dan is also teaching echolocation by tongue 
clicking that enables vision impaired people 
to orient and move through surrounding 
spaces safely and independently. Dan devel-
oped this technique as a boy and I fi nd this 
astonishing.
The documentary will also include the is-
sue of Muslim cab drivers refusing passen-
gers with guide dogs, and the way church 
and state are colliding in this challenge to 
human rights. Further, the documentary will 
explore the issues of integrating new tech-
nologies such as GPS tracking and talking 
devices that open up a new world of pos-
sibilities for guide dog users. As more guide 
dogs and assistance dogs are trained in Cu-
raçao, slowly we are seeing progress on the 
island that will make life easier for people 
with disabilities. For example, if Wagner 
and I are refused entry to any environment, 
then strangers will now step forward and try 
to help, explaining that Wagner is a specially 
trained dog. The awareness is improving.
Wagner provides a new level of dignity, 
self-reliance and freedom. He’s also great 
ambassador for The Seeing Eye because 
he’s a very friendly dog and people are al-
ways curious about him. Often people come 
by and ask questions or have their photo-
graph taken with him. Wagner is much more 
benefi cial than a cane. 
The cane seems too symbolic, identify-
ing you as “that poor blind person”, as many 
have the tendency to presume. 
It takes time, perseverance and patience. 
But gradually the momentum is building, 
more eyes and more doors are opening and 
we’re meeting more people who are taking 
International Journal of Orientation & Mobility • Volume 1, Number 1, 200882
the time to see and respect the real person be-
hind the disability. I’m still the same Laura 
I was before my vision was impaired. You’ll 
know that too, if you take the time to see.
Laura de Haseth Meddens, Founder of The Laura 
And Wagner Foundation, PO Box 8325, Curaçao, 
Netherlands Antilles; e-mail:<info@LauraAndWag-
ner.com>.Website: www.LauraAndWagner.org


Opening Eyes and Opening Doors

Gallimore, Ph.D., Desirée

Steer, Ph.D., Mike

International Journal of Orientation & Mobility • Volume 1, Number 1, 20086
Editorial
Welcome to the inaugural volume of the 
International Journal of Orientation & Mo-
bility (IJOM). Our website is at www.ijori-
entationandmobility.com The journal results 
from a recognition of the need for a publica-
tion specialising in orientation and mobility 
(O&M) that will facilitate the communica-
tion of a range of developments, issues, 
analyses, philosophies and technologies 
among professionals. Aided by such a jour-
nal as this, we in the O&M profession are 
assisted in refl ecting about, and enhancing 
our practice. We welcome submissions of 
original research and analyses, essays, con-
ceptual papers, innovative practice reports, 
evaluations, case studies, policy analyses, 
commentaries and debate on a wide variety 
of issues and topics related to the O&M of 
people who are blind or vision impaired.
It is important to acknowledge organi-
sations and individuals without whom this 
journal would not be possible. First, the 
RIDBC Renwick Centre, affi liated with 
the University of Newcastle, Australia, and 
Guide Dogs NSW/ACT, Australia both of 
whom sponsor its production. Thanks as 
well, to some of the world’s fi nest academ-
ics, professionals and leaders in O&M who 
generously provide direction to the editors 
and comprise our distinguished Editorial 
Advisory Panel; namely: Dr Bruce Blasch, 
Dr Nora Griffi n-Shirley, Dr Susanne Grün-
berger, Dr Kathleen Mary Huebner, Dr Steve 
La Grow, Dr Nurit Neustadt-Noy, and Dr 
Sandra Rosen. Appreciation is also extended 
to the peer reviewers who play an essential 
role in selection of the manuscripts that we 
publish. Finally, our thanks are extended to 
the contributing authors who believe in their 
research, practices and opinions, and who 
have the courage to submit their work to the 
blind peer review process that underpins the 
journal’s quality control.
Together, we work in a variety of coun-
tries and communities, and as a group, our 
contributors, whether advisors, reviewers 
or authors, have terrifi c skill and innovative 
ideas. We are all, at times faced with simi-
lar O&M scenarios, (though each is unique) 
that result largely from the cultural, environ-
mental and societal infl uences that affect the 
ways we work. Thus, it becomes the respon-
sibility of each of us to share our talent and 
experiences so that we continue to lay the 
foundation of learning for those who will 
succeed us, to build upon what we already 
know, and to strive for improved practice, 
so that the profession of O&M continually 
develops. 
This inaugural volume presents a vari-
ety of topics intended to be of great inter-
est to our readers. Topics are as diverse as 
Gleeson’s analysis of changes in perspec-
tives on Toxoplasmosis and Lucas’s descrip-
tion of a trial to determine the feasibility of 
a guide dog instructor vacancy being fi lled 
by a candidate who is blind. Our lead article 
by Blasch, La Grow, and Penrod deals with 
the concept of an environmental rating scale 
to systematically describe and rate travel 
environments for people with vision impair-
ment. Such an instrument offers instructors 
and clients a reliable method by which to 
judge the complexity of travel routes, and 
helps indicate a skill-set that a client re-
quires to safely and independently negotiate 
particular travel routes. The implications of 
the scale are far reaching. Through its use 
International Journal of Orientation & Mobility • Volume 1, Number 1, 2008 7
the client is empowered to determine his or 
her place of residency based on knowledge 
that their environment is of a particular but 
defi nable complexity.
Evidence of the use of dogs to lead people 
with vision impairment appears as far back 
as 79AD, with a wall painting in Pompeii 
portraying a man who is blind being led by a 
dog. Guide dogs remain a primary mobility 
aid although there is a dearth of recent em-
pirical evidence validating their use as mo-
bility aids. Lloyd’s two part study, examines 
the perceived effectiveness of the guide dog 
on travel performance, and describes chang-
es to travel habits, as well as the advantages 
and disadvantages of guide dog mobility in 
today’s environment. 
For those instructors who are not well 
versed in guide dog mobility, Joyce pres-
ents and describes three critically important 
factors that are ‘must knows’ when work-
ing with guide dog handlers and their dogs. 
These key factors are important when pro-
viding a range of programs to guide dog cli-
ents, for example, orientation or electronic 
aid programs.
At the forefront of our work with any mo-
bility aid, is of course the client. Although 
we attempt to listen and understand, it is al-
ways a challenge to fully appreciate the cli-
ent’s true perspectives and the individual’s 
experience of having a vision impairment. 
In her commentary, de Haseth Meddens 
goes some way in helping us appreciate this 
experience. She describes the acquisition of 
her vision impairment as a result of medi-
cal error and provides a revealing account 
of her journey as a person with sudden vi-
sion loss. de Haseth Meddens in becoming 
the fi rst guide dog handler in the Caribbean 
discusses the discrimination she experienced 
and introduces the reader to the Foundation 
she has recently established. 
Echolocation is a skill sometimes used 
by clients in addition to mobility aids in or-
der to assist their detection of obstacles and 
maintain orientation. Interestingly, Brazier 
found that her client sample preferred using 
non-traditional ‘below the waist’ methods to 
generate sound rather than such ‘above the 
waist’ methods as tongue or fi nger click-
ing. Brazier’s conclusions remind mobility 
instructors of the importance of considering 
individual client need and expectation, rath-
er than following a generic recipe approach 
to training.
Serving individual need is also the cen-
tral theme in Sauerburger, Siffermann, and 
Rosen’s report on their principles for pro-
viding O&M to people with vision impair-
ment and multiple disabilities. The formula-
tion of these principles results from years of 
observation and application that the authors 
have found both reliable and effective. It is 
important to note that their report includes 
the term ‘deaf-blind’ rather than ‘deafblind’. 
Deafblind is the term adopted by the Austra-
lian Deafblind Council and by the national 
organisation ‘Sense’ in the United Kingdom. 
Much of the international literature also uses 
the term deafblind, the rationale being that 
the condition is simply not a combination of 
Deaf and Blind, but a disability in its own 
right. However, IJOM as an international 
journal respects the recent decision by the 
American Association of the Deaf-Blind to 
continue using the hyphenated term “deaf-
blind” and acknowledge that philosophical 
variation and preference will occasionally 
occur with regard to terminology. In this and 
similar instances, the author’s preferred ter-
minology will be used. 
International Journal of Orientation & Mobility • Volume 1, Number 1, 20088
Effective multi-disciplinary team col-
laboration is both advocated and questioned 
in some reports. Ravenscroft questions the 
effectiveness of multi-agency rehabilitation 
teams, reporting that as a consequence, many 
adults and children have vision impairment 
problems that go unrecognised and remain 
untended. Ravenscroft provides insight into 
why this continues to occur. Alternatively, 
Wells highlights the developmental-based 
O&M needs of children that require the ex-
pertise of family members and profession-
als including instructors knowledgeable in 
early childhood education, paediatric phys-
iotherapists and specialist therapists. Simi-
larly, Scott describes the importance of the 
Western Australian Early Intervention Team 
Service that includes a child-centred O&M 
program. Through that service, O&M pro-
grams for children are introduced as soon as 
the child begins to walk, and adapted guid-
ing techniques are introduced as well as the 
long cane once the child is able to balance 
and move independently. Scott describes the 
advantages and method of introducing the 
long cane at an early age.
Finally, Chambers and Dannaway provide 
sobering observations about the necessity of 
including physiotherapy intervention if the 
effectiveness of some O&M programs is to 
be increased.
Readers will observe that authors present 
a variety of perspectives, innovative prac-
tices and possibly transformational ideas. 
This is the hard work that catalyses neces-
sary change and evolution in a profession 
that must keep pace with the advances and 
expectations of our clients in a progressive 
world.
Desirée Gallimore Ph.D. & Mike Steer Ph.D.


Editorial

Sauerburger, M.A., C.O.M.S., Dona

Siffermann, M.A., M.Ed., C.O.M.S., Eileen

Rosen, Ph.D., C.O.M.S., Sandra

International Journal of Orientation & Mobility • Volume 1, Number 1, 200852
Principles for Providing Orientation 
and Mobility to People with 
Vision Impairment and Multiple 
Disabilities 
Dona Sauerburger, Eileen Siffermann, and Sandra Rosen
Providing orientation and mobility 
(O&M) services to people who have disabil-
ities in addition to vision impairment pres-
ents an exciting challenge. It is especially re-
warding when it enables students to achieve 
a meaningful life which they and their 
families might not have thought possible. 
The O&M specialist may feel overwhelmed 
when beginning to work with these students 
because he or she may be unfamiliar with 
factors such as assessment techniques which 
will lead to appropriate strategies and equip-
ment needed to achieve success and a great 
level of independence. Through the authors’ 
experiences working with people with mul-
tiple disabilities, they have learned basic 
principles for success, which are explained 
in this practice report. These principles are 
as follows:
Understand that multiple disabilities have • 
more impact than the simple addition of 
each disability. 
Have high expectations for success. • 
Be functional in the assessment and • 
instruction. 
Be creative and fl exible, and design the • 
program for the individual. 
Encourage participation in the community, • 
even if it cannot be done independently. 
Find resources and information related to • 
each of the disabilities. 
Work with a team or in consultation with • 
others who have expertise in the addition-
al disabilities. 
Multiple disabilities have more 
impact than the simple addition of 
each disability
Each combination of disabilities presents a 
unique situation, with challenges that add up 
to more than the challenges of each disability 
added together. People who have disabilities 
other than vision impairment normally use 
adapted techniques that rely on their vision 
to function, and many of the strategies and 
adaptive devices that people with vision im-
pairments use to travel safely and communi-
cate with the public require normal hearing, 
cognitive functioning, and mobility. Many 
of these adaptive strategies are not feasible 
for blind people who also cannot hear well, 
cannot understand the strategy or process 
the information, or cannot move safely and 
maintain their balance. So when vision loss 
and other disabilities are added together, the 
impact on people’s options and their ability 
to function are not added together, but rather 
they are multiplied.
International Journal of Orientation & Mobility • Volume 1, Number 1, 2008 53
Have high expectations for 
success
When expectations are high, students can 
be inspired and motivated to achieve their 
best. Therefore keep an open mind and let 
your students teach you about how much 
they can achieve, and encourage them to 
reach their potential for independent travel. 
Be aware that in spite of the seemingly in-
surmountable challenges that multiple dis-
abilities can present to people with vision 
impairment, they can achieve high levels of 
independent travel, often beyond the level at 
which people thought they were capable. For 
example, people who are completely blind 
and have moderate cognitive disabilities 
are using buses and travelling to and from 
their homes and their work places or centres 
every day by themselves. People who are 
completely blind and have severe cognitive 
disabilities are travelling independently in-
side their home and workplace. People who 
are completely blind and profoundly deaf 
or using a wheelchair or mobility aid travel 
around the world by themselves.
Be functional in the assessment 
and instruction
Students with multiple disabilities should 
be assessed within the activity and environ-
ment in which they naturally travel. In many 
cases, instruction should be done at the times 
and places that the student would normally 
travel. For example, assessment of the risk 
of deaf-blind students to cross streets should 
be done at the times of day that the student 
will be travelling there. 
When working with students with a cog-
nitive as well as a visual disability, the as-
sessment should note when mobility tasks 
are critical to the student’s daily/weekly 
schedule. During this process the O&M spe-
cialist should make several direct observa-
tions of the student within the normal envi-
ronments of school/work, residence, and the 
community, such as when the students ride 
from their residence to school/work, and at 
their regularly scheduled lunch time. As part 
of this assessment it is also very important 
to obtain information on the student’s visual 
function, hearing function, psychological 
function and medical status. The O&M spe-
cialist might request additional assessments 
from the audiologist, the occupational thera-
pist and the physiotherapist. 
The assessment is then shared with the 
student and the person(s) who made the re-
ferral. The O&M specialist sets forth areas 
and circumstances in which O&M skills 
could be taught including any mobility de-
vices which might be used. The team prior-
itises the areas of instruction and identifi es 
specifi c skills to be worked on by the O&M 
specialist. For example, it might be very 
important to the classroom teacher that the 
student learns to leave the classroom and, 
with only distance supervision, travel inde-
pendently to the school cafeteria.
The O&M specialist then develops an 
instructional plan to address the identifi ed 
O&M skill. The instruction on that skill will 
be scheduled at the time the activity occurs 
during the day.
Be creative and fl exible, and 
design the program for the 
individual
Standard “recipe” strategies and solutions 
that are successful for most people who 
have a vision impairment may not work for 
those with additional disabilities, but there 
are ways to get around most challenges. Be 
International Journal of Orientation & Mobility • Volume 1, Number 1, 200854
creative and willing to try new strategies 
and ideas developed for the individual stu-
dent with multiple disabilities. For example, 
for students who use aids to walk or move, 
there are specialised techniques to use a long 
cane together with the aid, and even tech-
niques in which the aid can replace the long 
cane when necessary. Deaf-blind students 
who cannot get information from hearing 
may prefer to slide their cane rather than use 
touch technique, and may prefer to follow 
a building or grass line rather than walking 
along the middle of a sidewalk as we nor-
mally teach blind students. In this way they 
can be taught to maintain their alignment 
and orientation while travelling. O&M pro-
grams for people who are deaf-blind must 
also include a systematic program to teach 
them to communicate with the public, using 
techniques that are appropriate for the indi-
vidual student. 
Encourage participation in the 
community, even if it cannot be 
done independently
All people have the right to acquire skills 
which allow them to function, at least in 
part, in a wide variety of environments and 
activities in their community. Experience in 
the community should not be denied to any 
people because they are unable to perform 
certain activities without assistance. For ex-
ample the student might learn to develop a 
shopping list and accompany someone to 
the grocery store to select the items; attend 
a sports/exercise club after learning how 
to get around the building independently; 
participate in a work program sorting sil-
verware at a cafeteria; sorting clothing at a 
thrift shore; stacking paper or crushing cans 
at a recycling center. Even though students 
may be able to only partially complete the 
tasks required to do these activities indepen-
dently, they can still participate, getting as-
sistance when appropriate.
Find resources and information 
related to each of the disabilities
None of us can be experts in all things, 
nor can it be expected that we know all that 
is necessary to work with all students. Thus 
we need to know where to get help and 
resources.
We should become familiar with profes-
sionals and agencies which serve people 
with other disabilities, as well as sources of 
devices and equipment used by people with 
other disabilities. For example, physiothera-
pists are great sources of information about 
gross motor function and use of aids such 
as wheelchairs, canes, and walkers, and oc-
cupational therapists can help with fi ne mo-
tor issues and adapted techniques to perform 
daily living skills.
A wealth of information about various 
disabilities is also available in literature, as 
well as information about serving people 
who have vision impairment and additional 
disabilities. The most notable of these is The 
Foundations of O&M, Second Edition by 
AFB Press, and the third edition is planned 
to be even more extensive and useful.
Work with a team or in 
consultation with others who 
have expertise in the additional 
disabilities
The benefi ts of working with others can 
start with administrators. All students have 
the greatest opportunity for success when 
the O&M instructor works together with 
International Journal of Orientation & Mobility • Volume 1, Number 1, 2008 55
program administrators. When those who 
are responsible for funding and managing 
the program understand the students’ needs 
for O&M as well as the need of O&M spe-
cialists for training and resources to serve 
special populations, they are better able to 
support and facilitate the O&M program. 
Further, when O&M instructors work with 
and understand the program administrators, 
they are better able to use or promote re-
sources to enhance the O&M instruction. 
When providing O&M to students with 
multiple disabilities it is considered best 
practice for the O&M specialist to consult, 
or work together as a team, with others. This 
is because students with multiple disabilities 
have needs that are beyond the job descrip-
tion or body of knowledge that is normally 
expected of O&M specialists. It is unethi-
cal and often ineffective or even detrimen-
tal to provide services outside of our area 
of expertise. Working or consulting with 
others makes the best use of resources, and 
provides support when consultants or team 
members suggest strategies and help brain-
storm solutions.
Sometimes all that is needed is consulta-
tion, where the O&M specialist asks others 
for information or ideas to meet the complex 
O&M needs of the student, after which the 
O&M specialist provides the instruction, 
consulting again only if needed. At other 
times, the O&M specialist works with others 
as a team during the entire O&M program. 
The team members assess needs and devel-
op goals together, share expertise and ideas 
throughout the instructional program, and 
take equal responsibility for monitoring the 
progress of the student and reinforcing skills.
Usually, however, the best model for pro-
viding O&M to any particular student with 
multiple disabilities is somewhere in be-
tween the two extremes of consulting and 
team work. Some of the program develop-
ment and instruction is done as a team, and 
some of it done by the O&M specialist alone, 
with consultation as needed. 
Which professionals are chosen to serve 
as consultants or team members to provide 
O&M service to students with multiple dis-
abilities will depend on the characteristics of 
the student; what support or knowledge the 
O&M specialist needs in order to be able to 
serve that student appropriately; and what 
resources and personnel are available in that 
culture/community to students with those 
disabilities. These consultants and team 
members typically include physiotherapists; 
occupational therapists; professionals who 
serve people with cognitive or hearing dis-
abilities such as special education teachers 
or communication specialists; travel instruc-
tors and job coaches for people with cog-
nitive, physical, or other disabilities; city 
planners and engineers. Often, people who 
should be consulted or part of the team be-
cause they know about the student’s special 
needs are the family or staff who live and 
work with the student and who provide the 
student with emotional support. Of course, 
the most important person to consult and be 
a member of the team is the student.
Usually, the professionals and personnel 
who are consulted or are part of the team 
know little or nothing about blindness and 
what people can achieve without vision. 
Thus it is important that O&M specialists: 
share with the others•  their expertise about 
O&M strategies and adaptations for peo-
ple who have a vision impairment; 
International Journal of Orientation & Mobility • Volume 1, Number 1, 200856
learn from the others information and • 
ideas about strategies in their area of ex-
pertise; and 
work together with the others to develop • 
solutions and strategies for the student to 
get around safely and effi ciently. 
Conclusion
No two O&M students are the same, and 
this is especially true of students with addi-
tional disabilities. For these students, O&M 
takes on new and fascinating challenges. Us-
ing the above principles, including seeking 
out information and working collaboratively 
with others, can go a long way to making 
a seemingly impossible task become both 
fun and successful. We wish you and your 
students the joy that can come from over-
coming challenges and being successful and 
effective. 
Dona Sauerburger, M.A., C.O.M.S., Orientation & 
Mobility specialist, 1606 Huntcliff Way Gambrills, 
Maryland 21054, USA; e-mail: <sauerburger@
mindspring.com>. Eileen Siffermann, M.A., M.Ed., 
C.O.M.S., Orientation & Mobility specialist, 8697 
Arnold Palmer Dr., Tucson, AZ 85742 USA; e-mail: 
<ESifferman@aol.com>. Sandra Rosen, Ph.D., 
C.O.M.S., Department of Special Education, San 
Francisco State University, San Francisco, CA 94132, 
USA; e-mail: <srosen@sfsu.edu>.


Principles for Providing Orientation and Mobility to People with Vision Impairment and Multiple Disabilities

Lucas, M.A., C.O.M.S., Kristin

Inclusive Employer: A Guide Dog School&rsquo;s Trial to Employ a Blind Instructor

Blasch, Ph.D., Bruce B.

La Grow, Ed.D., Steven

Penrod, Ed.D., William

Environmental Rating Scale for Orientation and Mobility

Lloyd, Ph.D., Janice K.F.

Stafford, MVB, MSc., Ph.D., FRCVs, MACVSC., Kevin J.

Budge, Ph.D., R. Claire

The Guide Dog as a Mobility Aid Part 1: Perceived Effectiveness on Travel Performance

Gleeson, B. App. Sc., (Phty), M. Spec. Ed., Michael G.

International Journal of Orientation & Mobility • Volume 1, Number 1, 2008 73
Should We Rethink 
Toxoplasmosis?
Michael G. Gleeson
Historically, acute infections by Toxoplasma gondii (T. gondii) were not considered 
problematic in children and adults. Congenital infections caused concern due to 
effects on the developing foetus. Unless severe, symptoms such as chorioretinitis 
often only appeared later with periodic reactivation of chronic infection. Current 
thinking about the role of T. gondii has changed substantially. Researchers now 
believe that acute infections in children and adults, and their periodic reactivation 
once the condition is chronic, may be responsible for a much larger percentage 
of eye disease than was previously thought, and may play a role in other systemic 
illnesses. Added to this, congenital T. gondii infection has recently been implicated 
in schizophrenia, which makes it timely for a reappraisal of this condition, its 
prevention and the implications for Orientation and Mobility (O&M) instructors.
Toxoplasmosis is a systemic illness 
caused by the protozoan parasite Toxoplas-
ma gondii (T. gondii). Enlarged lymph nodes 
are frequently observed, and fever, fatigue, 
muscle pain, sore throats and headaches 
may be present. This mimics other infec-
tious diseases (Hill & Dubey, 2002), so may 
go undiagnosed. Prevalence data from the 
USA estimate 23.6% of the population over 
12 to be antibody positive (Jones, Kruszon-
Moran, & Wilson, 2003) and an estimated 
billion people are infected worldwide (Val-
lochi, Nakamura, Schlesinger, Martins, Sil-
veira, Belfort, & Rizzo, 2002).
Orientation and Mobility (O&M) instruc-
tors work closely with the vision impaired 
population and could be an important com-
munity resource for helping reduce infection 
rates through public education. The purpose 
of this paper is to give O&M instructors 
up to date information regarding Toxoplas-
mosis, both clinical and practical, so that 
their recommendations are based on current 
thinking. The most recent estimates of con-
genital infection are 1 in 10,000 live births 
in the USA (Jones, Lopez, Wilson, Schulkin, 
& Gibbs, 2001). A small percentage will 
have noticeable ocular involvement imme-
diately, but most develop it later, often as 
teenagers or young adults (Rothova, 1999). 
Until recently it was widely held that most 
Toxoplasmic chorioretinitis in older chil-
dren and adults was due to reactivation of 
latent congenital infection (Hayde & Pollak, 
1999; Hill & Dubey, 2002; Rothova, 1999), 
but there is mounting evidence that postna-
tally acquired infection may be an important 
cause of ocular disease (Gilbert & Stanford, 
2000; Holland et al., 1999; Rothova, 2003; 
Smith & Cunningham, 2002). 
Life cycle of T. gondii
The life cycle of T. gondii is complex, and 
humans can acquire the infection through 
International Journal of Orientation & Mobility • Volume 1, Number 1, 200874
multiple routes. The organism has a num-
ber of forms, but only sexually reproduces 
in the intestines of cats. Infected cats shed 
up to ten million oocysts in their faeces after 
an initial infection, which sporulate within 
a few days. Warm wet conditions favour 
persistence over dry or colder conditions, 
which impacts on geographical prevalence. 
Oocysts persist in soils for months or even 
years under ordinary conditions (Frenkel, 
1999) and can be mechanically spread by 
fl ies, cockroaches, dung beetles and earth-
worms and even carried onto food (Hill & 
Dubey, 2002). The oocysts are ingested by 
birds and mammals, which along with hu-
mans are intermediate hosts.
T. gondii fi rstly assumes a rapidly mul-
tiplying form, the tachyzoite, within inter-
mediate host cells, which is responsible for 
initial tissue destruction. With an immune 
response and antibody development, the 
parasite forms cysts within host tissues as 
the slowly multiplying bradyzoite, the latent 
form of chronic infection (Frenkel, 1999). 
Given that T. gondii reproduction in cats 
is sexual, new strains of the organism are 
constantly emerging. This means that those 
already infected can be re-infected with po-
tentially more virulent strains at any time, 
further complicating their retinal health. 
O&M instructors can be instrumental in 
encouraging recommended hygiene prac-
tices that may minimise this possibility dur-
ing regular contact with clients and their 
families.
Common transmission routes
Ingestion accounts for most infection, ei-
ther as oocysts from cat fecal contamination, 
or as tissue cysts in meat (Hill & Dubey, 
2002). T. gondii is not resistant to freezing, 
but household freezers cannot be relied upon 
due to variable performance. Cooking meat 
to an internal temperature of 66°C in a con-
ventional oven kills cysts, but microwaves 
have not been shown to be reliable (Dubey, 
1999). Once consumed, digestive enzymes 
break down the cyst wall, but viable bra-
dyzoites survive long enough to infect the 
new host. 
Reactivation in the immune 
compromised
Initial infection in immunocompetent 
adolescents and adults may go unnoticed or 
follow a mild course. Immunosuppression 
caused by AIDS, chemotherapy, following 
transplants and for lymphoproliferative dis-
orders can all result in reactivation of pre-
existing T. gondii infections (Jones, et al., 
2001; Smith & Cunningham, 2002). Addi-
tionally, elderly members of the population 
have been identifi ed as at risk of aggressive 
disease (Smith & Cunningham, 2002). If 
O&M instructors are aware that a client is 
immunosuppressed, they can not only act 
as an information resource, but should take 
care that their own hygiene does not com-
promise that of their client. 
Congenital or acquired?
Current evidence suggests that at least 
two thirds of ocular Toxoplasmosis may 
be caused by postnatal infection (Gilbert 
& Stanford, 2000). In the past, the ‘typical’ 
chorioretinal scars were often what pointed 
to a diagnosis but atypical presentations are 
being reported more commonly (Smith & 
Cunningham, 2002), and intraocular infl am-
matory reactions have been reported in the 
absence of old scars (Holland, Muccioli, 
Silveira, Weisz, Belfont, Jun, & O’Connor, 
International Journal of Orientation & Mobility • Volume 1, Number 1, 2008 75
1999). According to Rothova (2003), those 
acquiring ocular Toxoplasmosis in the acute 
stage of infection are mostly elderly, and 
additional complications can disguise the 
original lesion, making correct diagnosis 
diffi cult. 
Systemic and behavioral effects 
of T. gondii infection
Increasingly, non-ocular manifestations 
are coming to light. There have been re-
ports of cysts found among tumor cells in 
pituitary adenoma (Zhang, Li, Hu, Cheng, & 
Huang, 2002), researchers in Turkey found 
a signifi cantly higher incidence of T. gondii 
serpositivity among patients with cirrhosis 
of the liver (Ustun, Aksoy, Dagci, & Ersoz, 
2004), and research on mice in Brazil “sug-
gest that infection with T. gondii accelerates 
atherosclerotic development” (Portugal et 
al., 2004, p. 3571). 
Researchers in the UK looked at the abil-
ity of T. gondii to manipulate the behaviour 
of intermediate hosts in order to increase 
the likelihood of predation by its defi nitive 
host, thereby ensuring the completion of its 
life cycle. Rats usually avoid areas where 
there are signs of a cat’s presence, but the 
researchers found that infected rats had an 
altered perception of cat predation risk, and 
in some cases their aversion turned into at-
traction (Berdoy, Webster, & Macdonald, 
2000). These results may help provide a par-
tial explanation for altered brain function in 
infected humans. 
Laboratory studies have shown that la-
tent Toxoplasmosis prolongs reaction times, 
a study in the Czech Republic fi nding that 
subjects with latent T. gondii infection have 
a signifi cantly increased risk of traffi c ac-
cidents compared to non-infected subjects 
(Flegr, Havlicek, Kodym, Marek, & Zbynek, 
2002). O&M instructors should be aware of 
these slower reaction times in clients with 
Toxoplasmic lesions, and slowing down the 
pace of instruction and expectations in com-
plex environments is recommended.
Not only may reaction times be affected. 
Torrey and Yolken (2003) relate three cases 
in which schizophrenia was fi rst diagnosed, 
being retracted later when further neuro-
logical symptoms developed. Brown et al., 
(2005, pp. 771-72) demonstrated that “el-
evated maternal IgG antibody to Toxoplas-
ma is associated with an increased risk of 
schizophrenia and other schizophrenia spec-
trum disorders” for the developing foetus in 
adulthood in a study of a large birth cohort 
born between 1959 and 1967.
Many studies have indicated that schizo-
phrenia has its origins in earlier stages of 
brain development even though symptoms 
may not manifest until late adolescence or 
early adulthood (Torrey & Yolken, 2003). In 
cell cultures, T. gondii selectively affected 
glial cells, especially astrocytes (Creuzet et 
al., 1998, cited in Torrey & Yolken, 2003) 
and postmortem studies of schizophren-
ics report glial cell abnormalities, includ-
ing reduced numbers of astrocytes (Doyle 
& Deakin, 2002, cited in Torrey & Yolken, 
2003). 
France has a high rate of T. gondii infec-
tion, and is reported to have 50% higher fi rst-
admission rates for schizophrenia (Van Os, 
Galdos, Lewis, Buurgeois, & Mann, 1993, 
cited in Torrey & Yolken, 2003). Likewise, 
rural Ireland has high seropositivity and a 
high prevalence of schizophrenia (Halonen, 
Lyman, & Chiu, 1996, cited in Torrey & 
Yolken, 2003). T. gondii is known to have 
an affi nity for neural tissue, and infection 
International Journal of Orientation & Mobility • Volume 1, Number 1, 200876
becomes chronic after a short acute ill-
ness, providing a capacity for long-term ill-
ness starting in early life (Torrey & Yolken, 
2003). 
Public health prevention
Transmission of T. gondii is largely oral, 
so simple hygiene measures are currently the 
most effective preventive strategy. Dubey 
(1999) recommends washing hands and 
implements thoroughly with soap and wa-
ter after handling meat. Rare and raw meats 
should be avoided, and meat should be 
cooked to 66˚C throughout in conventional 
ovens, as microwaves are unreliable. Gloves 
should be worn when gardening and vegeta-
bles washed thoroughly before eating.
Cats should only be fed dry, canned or 
cooked food because they usually only be-
come infected from eating infected tissues. 
Gloves should be worn when handling cat 
litter, which should be emptied daily. Gar-
bage cans should be covered to prevent 
scavenging and sandpits should be covered 
when not in use to minimise fecal contact 
with children. Feral cats are a major res-
ervoir of the infection, so cats should be 
spayed to control the feline population, and 
dead carcasses on farms should be removed 
promptly to prevent scavenging (Dubey, 
1999; Thulliez & Romand, 1999).
Additionally pregnant women should 
make arrangements with someone else to 
change cat litter trays if possible and hands 
should be washed thoroughly after contact 
with cats, soil and raw meat. Raw fruit and 
vegetables should also be washed thoroughly 
before consumption and avoided when eat-
ing out if this cannot be confi rmed (Thulliez 
& Romand, 1999). Although not universally 
implemented, blood tests and screening are 
available, so Toxoplasmosis can be dis-
cussed with a General Practitioner. Enlarged 
lymph nodes in the neck area should not be 
ignored. O&M instructors should familiar-
ise themselves with these recommendations 
so that they can act as a resource for clients 
and their families and for the wider commu-
nity when appropriate situations arise. 
Conclusion
The cost-benefi t of mass screening is 
still being debated worldwide, but Austria 
implemented antenatal screening in 1975, 
and France followed in 1978. Establishing 
the recency of infection is important dur-
ing pregnancy in order to minimise damage 
to the fetus, and there is not one clear test 
that can do this at present (Hill & Dubey, 
2002). Prenatal drug regimens do reduce the 
severity of sequelae among infected infants, 
but they do not infl uence congenital trans-
mission rates (Jones et al., 2001) and 50% 
of those diagnosed develop recurrences of 
ocular infections within 3 years regardless 
of treatment given (Rothova, Meenken, & 
Builentuis, 1993, cited in Ambrose-Thomas 
& Peterson, 1999). 
Given all of this, the public health mes-
sage needs to be reclarifi ed and rebroadcast 
in the light of emerging fi ndings. Increas-
ingly atypical ocular presentations are be-
ing reported in the literature, and concern 
regarding a possible role for T. gondii in 
schizophrenia and other illnesses has been 
raised. The contribution of Toxoplasmosis 
to ocular, systemic, neurological and psy-
chiatric diseases, whether by congenital 
or acquired routes, needs to be established 
with some urgency. There are huge medical, 
economic, and public health consequences, 
International Journal of Orientation & Mobility • Volume 1, Number 1, 2008 77
the seriousness of which may be currently 
underestimated. 
References
Ambroise-Thomas, P., & E. Petersen (Eds.). 
(1999). Congenital Toxoplasmosis: Sci-
entifi c background, clinical management 
and control. New York: Springer. 
Berdoy, M., Webster, J. P., & Macdonald, D. 
W. (2000). Fatal attraction in rats infected 
with Toxoplasma gondii. Proceedings of 
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1594.
Brown, A. S., Schaefer, C. A., Quesenberry 
Jnr, C. P., Lui, L., Babulas, V. P., & Suss-
er, E. S. (2005). Maternal exposure to 
Toxoplasmosis and risk of schizophrenia 
in adult offspring. American Journal of 
Psychiatry, 162(4), 767-773.
Dubey, J. P. (1999). The scientifi c basis for 
prevention of Toxoplasma gondii infec-
tion. In P. Ambroise-Thomas, & E. Pe-
tersen, (Eds.). Congenital Toxoplasmo-
sis: Scientifi c background, clinical man-
agement and control (pp. 271-276). New 
York: Springer.
Flegr, J., Havlicek, J., Kodym, P., Marek, 
M., & Zbynek, S. (2002). Increased risk 
of traffi c accidents in subjects with latent 
Toxoplasmosis: A retrospective case-
control study. BMC Infectious Diseases, 
2(11), 6. Retrieved May 31, 2006, from 
Ovid.
Frenkel, J. K. (1999). Biology of Toxoplas-
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Petersen (Eds.), Congenital Toxoplasmo-
sis: Scientifi c background, clinical man-
agement and control (pp. 9-20). New 
York: Springer.
Gilbert, R. E., & Stanford, M. R. (2000). Is 
ocular Toxoplasmosis caused by prenatal 
or postnatal infection? British Journal of 
Ophthalmology, 84, 224-226.
Hayde, M., & Pollack, A. (1999). Clinical 
Picture: Neonatal signs and symptoms. 
In P. Ambroise-Thomas & E. Petersen 
(Eds.), Congenital Toxoplasmosis: Sci-
entifi c background, clinical management 
and control (pp. 153-164). New York: 
Springer.
Hill, D., & Dubey, J. P. (2002). Toxoplasma 
gondii: Transmission, diagnosis and pre-
vention. Clinical Microbiology and Infec-
tion, 8(10), 634-640.
Holland, G. N., Muccioli, C., Silveira, C., 
Weisz, J. W., Belfont, R. Jun., & O’Connor, 
G.R. (1999). Intraocular infl ammatory 
reactions without focal necrotizing retin-
ochoroiditis in patients with acquired sys-
temic Toxoplasmosis. American Journal 
of Ophthalmology, 128(4), 413-420.
Jones, J. L., Kruszon-Moran, D., & Wilson, 
M. (2003). Toxoplasma Gondii infection 
in the United States, 1999-2000. Emerg-
ing Infectious Diseases, 9(11), 1371-
1374.
Jones, J. L., Lopez, A., Wilson, M., Schulkin, 
J., & Gibbs, R. (2001). Congenital Toxo-
plasmosis: A review. Obstetrical & Gyne-
cological Survey, 56(5), 296-305.
Portugal, L. R., Fernandes, L. R., Cesar, 
G. C., Santiago, H. C., Oliveira, D. R., 
Silva, N. M., Silva, A. A., Lannes-Viera, 
J., Arantes, R. M. E., Gazzinelli, R. T., 
& Aalvarez-Leite, J. I. (2004). Infection 
with Toxoplasma gondii increases athero-
sclerotic lesion in Apo-E defi cient mice. 
Infection and Immunity, 72(6), 3571-
3576.
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Rothova, A. (1999). Recurrent ocular dis-
ease in congenital Toxoplasmosis: Clini-
cal manifestations. In P. Ambroise-Thom-
as & E. Petersen (Eds.), Congenital Toxo-
plasmosis: Scientifi c background, clinical 
management and control (pp. 215-229). 
New York: Springer. 
Rothova, A. (2003). Ocular manifestations 
of Toxoplasmosis. Current Opinion in 
Ophthalmology, 14(6), 384-388.
Smith, J., & Cunningham, E. T. (2002). 
Atypical presentations of ocular Toxo-
plasmosis. Current Opinion in Ophthal-
mology, 13(6), 387-392. 
Thulliez, P., & Romand, S. (1999). Prenatal 
screening and prevention of congenital 
Toxoplasmosis in France. In P. Ambroise-
Thomas & E. Petersen (Eds.), Congenital 
Toxoplasmosis: Scientifi c background, 
clinical management and control (pp. 
293-298). New York: Springer.
Torrey, E. F., & Yolken, R. H. (2003). 
Toxoplasma gondii and Schizophrenia. 
Emerging Infectious Diseases, 9(11), 
1375-1380.
Ustun, U., Aksoy, U., Dagci, H., & Ersoz, 
G. (2004). Incidence of Toxoplasmosis in 
patients with cirrhosis. World Journal of 
Gastroenterology, 10(3), 452-454.
Vallochi, A. L., Nakamura, M. V., Schle-
singer, D., Martins, M. C., Silveira, C., 
Belfort Jnr, R., & Rizzo, L. V. (2002). 
Ocular Toxoplasmosis: More than just 
meets the eye. Scandinavian Journal of 
Immunology, 55, 324-328.
Zhang, X., Li, Q., Hu, P., Cheng, H., & 
Huang, G. (2002). Two case reports of 
pituitary adenoma associated with Toxo-
plasma gondii infection. Journal of Clini-
cal Pathology, 55, 965-966.
Michael G. Gleeson, B. App. Sc., (Phty), M. Spec. 
Ed., (Sensory Disability), O&M instructor, Guide 
Dogs NSW/ACT, 2-4 Thomas Street, Chatswood, NSW 
2067, Australia; e-mail: <mgleeson@guidedogs.com.
au>.


Should We Rethink Toxoplasmosis?

Chambers, Louise

Dannaway, Jasan

International Journal of Orientation & Mobility • Volume 1, Number 1, 2008 87
A Balance Act: Physiotherapy as 
a Prerequisite to Orientation and 
Mobility Services
Louise Chambers and Jasan Dannaway
The School of Physiotherapy, Faculty of Health Sciences, University of Sydney, 
Australia initiated a community practicum for fourth year physiotherapy students. 
The goal was to broaden student’s perspectives about how allied health areas such 
as Orientation & Mobility (O&M) services are movement based similar to that of 
physiotherapy services. The authors participated in a fi ve-week practicum at an 
organisation that provides O&M services to clients with vision impairment. It was 
observed that some of the O&M programs would have benefi ted from physiotherapy 
input that would have assured the long term success of O&M programs.
What is physiotherapy?
Physiotherapy is a therapeutic health pro-
fession concerned with enhancing mobility 
and quality of life using clinical reasoning 
to deliver the most suitable drug-free treat-
ment for movement-based injury or condi-
tion. Treatment includes joint mobilisation 
and manipulation, therapeutic exercise and 
stretches, electro physical agents (such as 
hot packs, ice and ultrasound) and breathing 
exercise. Services are available to the com-
munity in varied settings as private practice, 
sports facilities, hospitals, schools, universi-
ties, public health organisations, community 
centres, aged care facilities and workplaces.
Practicum observation
During the practicum, the authors ob-
served O&M instructors working with a 
range of clients with vision impairment; 
travelled under blindfold with a guide, pre-
sented movement-based workshops to peo-
ple with multidisabilities and conducted fall 
prevention workshops to mature age people 
with vision impairment. From observation, 
it seems essential for people with vision im-
pairment to have sensorimotor skills, such 
as proprioception, balance, vestibular func-
tions and, at times, to use a mobility aid to 
assist independent travel. However it was 
observed that some clients lacked some of 
these core body characteristics and conse-
quently found independent travel very chal-
lenging. Remarkably, in the state of NSW 
there is only one organisation that provides 
O&M services that also employs physio-
therapists to specifi cally work alongside 
O&M instructors to directly compliment 
their O&M programs. 
The importance of physiotherapy 
as a prerequisite to orientation & 
mobility programs
Throughout the practicum it was ob-
served that there was a difference in terms 
of motor development between children that 
International Journal of Orientation & Mobility • Volume 1, Number 1, 200888
had received physiotherapy services com-
pared with those that had not. Children that 
received services had developed superior 
motor skills such as the ability to roll, crawl, 
prop themselves up and walk. Without phys-
iotherapy intervention it is likely that chil-
dren with low vision or blindness might be 
exposed to predictable developmental risks. 
These risks include decreased postural tone, 
inability to balance, decreased incidental 
learning through play and observation, and 
decreased levels of motivation for the child 
to move. These movement issues will im-
prove only slightly or not at all unless ad-
dressed by thorough assessment and inter-
vention by a movement based professional 
such as a physiotherapist.
Physiotherapy intervention can improve 
muscle tone and postural upper and lower 
limb strength, balance, body awareness 
and movement stimulation. Intervention is 
achieved through a variety of games and 
tasks as tug of war, weights, stepping under 
and over objects and balance games all of 
which can be presented in a way to captivate 
the child’s attention and motivation. With-
out such intervention, as was observed, low 
muscle tone, reduced proprioception and im-
balance result all of which negatively reduce 
the effectiveness of O&M training.
It was also observed that some elderly 
clients with vision impairment were at risk 
of falls as a result of imbalance, postural 
and gait issues, reduced strength, reduced 
motivation to engage in mobility training, 
weight issues and decreased cardiovascular 
fi tness. Physiotherapy intervention, howev-
er, could have improved the conditions for 
these clients. Geriatric physiotherapy pro-
vides a range of services to meet the unique 
requirements of the maturing individual. 
Mobility can be restored through exercises 
to strengthen muscles, balance training to 
ease transfers and walking, and recommen-
dations of such assistive devices as walkers 
and canes can be made. 
The process of achieving adequate levels 
of orientation, mobility and independence 
requires the correction of movement and 
health issues. For example, the goal of reach-
ing a destination with the use of a long cane 
cannot be achieved without the strength to 
hold the cane correctly, strength and fl exibil-
ity in the leg, arm and wrist muscles to con-
trol the cane movement and the effi ciency 
to mobilise without muscle fatigue. Clients 
must have postural muscle tone to maintain 
posture while using the cane, and excellent 
shoulder stabaliser muscles, in order to stab-
alise the shoulder so that the wrist can also 
control the cane. In addition a person must 
have effective proprioception skills to be 
aware of their body position, thus increasing 
their safety when mobilising. Physiotherapy 
is integral in developing these skills, and is 
a prerequisite to the long term effectiveness 
O&M programs.
At present, there appear no consistent 
guidelines or processes in the state of NSW 
for the referral between professionals in vi-
sion impairment and physiotherapy. Guide-
lines need to be devised and networks cre-
ated so that full assessment and intervention 
can be recommended and delivered. This 
link between physiotherapy and O&M ser-
vices would create a more holistic interven-
tion for the client with the result of achiev-
ing increasingly effective long term O&M 
outcomes. 
O&M service providers could consider 
the integration of practising physiotherapists, 
paediatric and geriatric physiotherapists into 
their existing client service departments. 
International Journal of Orientation & Mobility • Volume 1, Number 1, 2008 89
This would ensure greater opportunities to 
provide physiotherapy services to a wider 
range of clients with the result of increasing 
referral numbers, the effectiveness of O&M 
programs and the number of programs able 
to be delivered successfully.
Louise Chambers, School of Physiotherapy, Faculty 
of Health Sciences, University of Sydney, PO Box 170, 
Lidcombe, NSW 1825, Australia; e-mail:< intl-info@
fhs.usyd.edu.au>. Jasan Dannaway, School of Phys-
iotherapy, Faculty of Health Sciences, University of 
Sydney, PO Box 170, Lidcombe, NSW 1825, Australia; 
e-mail:< intl-info@fhs.usyd.edu.au>.



A Balance Act: Physiotherapy as a Prerequisite to Orientation and Mobility Services

Ravenscroft, Ph.D., John

International Journal of Orientation & Mobility • Volume 1, Number 1, 2008 83
Shuffl ing the Deckchairs: 
Multi-agency Working and the 
Continuing Lack of Identifi cation of 
People with Vision Impairments
John Ravenscroft
Many orientation and mobility (O&M) professionals working to meet the needs of 
children and adults with vision impairment may do so as a part of multi-agency 
rehabilitation teams. However, from a study of current literature in the fi elds of vision 
impairment, multiple-disability and intellectual disability, it is apparent that multi-
agency participation does not invariably identify with accuracy, all those requiring 
a service. This article discusses how those professionals working in multi-agency 
frameworks support those in need when their service delivery agenda is based merely 
on a subset of the total population that should have their needs addressed. 
Much has recently been spoken and writ-
ten about multi-agency working and what 
multiple agency participation means for 
those services supporting family members 
with vision impairments. Current profes-
sional literature has a considerable amount 
of research that examines the benefi ts of 
multi-agency working. For example, Slop-
er (2004) indicates that families, who have 
been assigned key workers to act as the 
main coordinators of services they receive, 
have reported an improved quality of life. 
Sloper further claims that as a direct result 
of case-coordination families appear to re-
ceive better and quicker access to services, 
and consequently have better relationships 
with service providers than those who not 
been case-managed. Roaf (2002) has sug-
gested ways that multi-agency approaches 
have provided a shift from simple prob-
lem-solving towards a holistic approach to 
collaboration in service provision. Atkinson 
and her fellow workers (2002) have identi-
fi ed several positive outcomes for services 
that have adopted a multi-agency approach 
in service delivery. These outcomes include 
(a) access to services not previously avail-
able to children and families, (b) improved 
educational attainment and (c) a reduced 
need for more specialist services. It seems 
clear that adopting a multi-agency approach 
to service provision can lead to a win-win 
situation in which there are improved out-
comes for children and families with vision 
impairment, as well as in the provision of 
signifi cant benefi ts for the staff and services 
that are part of a multi-agency framework. 
The comprehensive rehabilitation team is 
an obvious example of multi-agency work-
ing. It is a team on which there may be re-
habilitation teachers, coupled with rehabili-
tation counsellors, working beside and with 
International Journal of Orientation & Mobility • Volume 1, Number 1, 200884
orientation and mobility (O&M) instructors, 
with input from low vision specialists. Occu-
pational therapists may also provide support 
by training or retraining individuals with mo-
tor diffi culties. There will be, at some level, 
participation from medical and allied medical 
staff and it would not be uncommon for the 
team to receive some support from a psychol-
ogist as well. If the client was located within 
an educational setting, this team would more 
than likely also receive input from a variety 
of educationalists as well as from other school 
staff. Consequently, many O&M instructors 
see themselves as part of an elaborate and so-
phisticated multi-agency team with the goal 
of meeting the needs of individuals within a 
wide ranging client group. 
However, I have started to become con-
cerned about the current use of ‘multi-agen-
cy working’ as a descriptive term. The term 
seems to me to be rapidly becoming one of 
the many ‘buzz words’ that people use, (as 
another example, ‘the paper-less offi ce’) a 
term that everyone uses these days, with all 
concerned declaring that they are part of a 
multi-agency team. Yet when we dig more 
deeply we discover that they are in fact still 
working in isolation, shuffl ing the deck 
chairs (so to speak), and generally surround-
ed by a paper volcano of printed material. 
Lloyd, Stead, and Kendrick (2001) de-
scribe multi-agency working practices as 
providing ‘a terminology quagmire’. For 
example, I am relatively sure that you, the 
reader, during your career, must have been 
involved in some inter-agency, joint work-
ing, multi-professional, cross sector collab-
orative team or other. There are a great many 
terms widely used to describe the multi-
agency concept, each representing a slightly 
different working practice. Just by turning 
up at work the opportunity of being part of 
an inter-agency team appears these days to 
be fairly high. 
But, and here is the crux of this article, 
if the benefi ts of multi-agency working are 
there for all to see, and as a result there are 
now more rehabilitation teams than ever 
before, teams specifi cally for adults with vi-
sion loss and teams specifi cally for children 
with vision loss all working within multi-
agency frameworks, why is it still the case in 
so many instances that far too many adults 
and children who have additional and mul-
tiple disabilities over and above their vision 
impairment have sight problems that are still 
unrecognised and who remain consequently 
untended. I will further illuminate this point 
by highlighting some articles in the vision 
impairment and intellectual disability arena 
that have recently identifi ed people with 
low vision and blindness who were previ-
ously unknown to these multi-agency based 
rehabilitation teams and thus prior to iden-
tifi cation were not receiving, for example, 
any support such as daily living skills and 
independent skills appropriate to the needs 
generated by their vision impairment. 
Vision impairment, multiple 
disability and intellectual disability
Looking back at the last decade, a rea-
sonably typical example illustrating people 
with an undetected and unknown vision im-
pairment is Broek, Janssen, Ramshorst, and 
Deen (2006) research indicating that 92% 
(N=76) and not 30% as previously thought, 
of people with severe and profound multiple 
disabilities in a Dutch care organisation were 
shown to have a signifi cant vision impair-
ment. Broek et al., reported that the severity 
of the vision impairment in their participants 
was closely related to severity of intellectual 
International Journal of Orientation & Mobility • Volume 1, Number 1, 2008 85
disability. Concomitantly, Splunder, Stilma, 
Bernsen, Arentz, and Evenhuis, (2003) stud-
ied 900 adults with intellectual disability 
and confi rmed Evenhuis’s (2001) study of 
672 adults with intellectual disability, fi nd-
ing that prevalence and severity of vision 
impairment are especially high with adults 
who have severe and profound intellectual 
disability. Splunder’s study also indicated 
that ‘non-refractive vision impairment is 
congenital or acquired at an early age,’ 
(Splunder et al., 2003, p.128), thus demon-
strating that this specifi c group could have 
been identifi ed earlier, and strategic and 
targeted rehabilitation services then imple-
mented. Again this type of lack of identifi ca-
tion and the subsequent non involvement by 
any rehabilitation team is reported by Kou-
tantos (2000) who confi rmed his hypothesis 
that there were many more children with vi-
sion impairments in Crete, a small country 
population than were previously known. 
What is common to these studies is that 
they had identifi ed people with previously 
unknown uncorrectable vision loss who were 
being supported by a variety of agencies but 
none of these people with signifi cant vision 
loss were getting support to address their vi-
sion impairment needs, including meeting 
their necessary and suffi cient rehabilitation 
requirements. 
The literature appears to confi rm Aitken’s 
(1997) contention that although the tradition-
al triage-like “lets deal with the most serious 
impairment fi rst” approach to serving chil-
dren with multiple disabilities is gradually 
changing due to developments in legislative 
frameworks, and is being replaced by multi-
agency working, there are still many profes-
sional boundaries that emphasise the primary 
disability of the individual, to the neglect of 
addressing the other needs that person may 
have. Interestingly enough, Aitken (1997) 
and Millar and Aitken (1996) further suggest 
that the term ‘multi disabled and visually im-
paired’ (MDVI) may create an artifi cial cat-
egorisation by referencing vision in the title. 
Other issues, for example, augmentative and 
alternative communication needs that could 
support rehabilitation may not be attended 
to, whether the service professional is part of 
a multi-agency team or not. 
Although Aitken (1997), and Millar and 
Aitken’s (1996) views appear to be at the 
opposing side of my stance, both sides agree 
that current practices that are part of multi-
agency partnerships do not fully identify the 
number of people requiring the services of 
specialist professionals including those from 
specialist rehabilitation teams. 
Ravenscroft, Blaikie, Macewen, O’Hare, 
Creswell, and Dutton (2008) ask these impor-
tant questions; Why is it that we still do not 
know how many people we should be serv-
ing? Why is it that we increasingly, it seems, 
do not know where all the individuals with 
disabilities in the population we are to serve 
are located? And why is it when we look into 
the near future, the answers to these very ba-
sic questions do not seem to be forthcoming?
Policy makers and planners of integrated 
service provision models, including those 
on rehabilitation teams aiming to meet the 
needs of people with vision impairment 
face the diffi cult task of delivering services 
based on information that may not describe 
the full scale or spectrum of people they 
should be serving. Perhaps a simple anal-
ogy would help to express my concerns. Not 
having accurate details about the numbers 
(and potential numbers) of service-users out 
there is surely like an architect planning a 
large public building, but not knowing how 
International Journal of Orientation & Mobility • Volume 1, Number 1, 200886
many people will go into it, or consequently 
what the internal and external requirements 
should be.
Without doubt, people with vision im-
pairments require an integrated multi-agen-
cy tailored service provision of which re-
habilitation teams are part, but in order to 
plan and develop such services, surely we, 
as supposedly well-trained and competent 
professional service providers, fi rst need ac-
curate demographic client profi les?
References
Aitken, S. (1997). Visual and additional 
impairments: Social perspectives and at-
titudes. The British Journal of Visual Im-
pairment, 15(3), 93-97. 
Atkinson, M., Wilkin, A., Stott, A., Doherty, 
P., & Kinder, K. (2002). Multi-agency 
Working: A detailed study (LGA Research 
Report 26). Slough: NFER. Retrieved 8 
August 2008 from http://www.nfer.ac.uk/
publications/other-publications/down-
loadable-reports/multi-agency-working-
a-detailed-study.cfm 
van den Broek, E.G. C., Janssen, C.G.C., 
van Ramshorst, T., & Deen, L. (2006). 
Visual impairments in people with severe 
and profound multiple disabilities: An in-
ventory of visual functioning. Journal of 
Intellectual Disability Research, 50(6), 
470-475.
Evenhuis, H. M., Theunissen, M., Denkers, 
I., Verschuure, H., & Kemme, H. (2001). 
Prevalence of visual and hearing impair-
ment in Dutch institutionalized popula-
tion with intellectual disability. Journal 
of Intellectual Disability Research, 45(5), 
457-464.
Lloyd, G., Stead, J., & Kendrick, A. (2001). 
Hanging on in there: A study of inter-
agency work to prevent school exclusion 
in three local authorities, London, Na-
tional Children’s Bureau.
Koutantos, D. (2000). A survey of children 
with VIMI in special schools in Crete. 
The British Journal of Visual Impairment, 
18(2), 73-77.
Millar, S. V., & Aitken, S. (1996).Voice out-
put communication aids. In N. Boxic & 
H. Murdoch (Eds.), Learning Through 
Interaction (pp. 116-131). London: David 
Fulton Publishers.
Ravenscroft, J., Blaikie, A., Macewen, C., 
O’Hare, A., Creswell, L., & Dutton, G. 
N. (2008). A novel method of notifi cation 
to profi le childhood visual impairment in 
Scotland to meet the needs of children 
with visual impairment. The British Jour-
nal of Visual Impairment, 26(2) 170-189. 
Roaf, C. (2002). Co-ordinating services 
for included children: Joined-up action. 
Buckingham: Open University Press.
Sloper, P. (2004). Facilitators and barriers 
for co-ordinated multi-agency services. 
Child Care, Health and Development, 
30(6), 571-580.
van Splunder, J., Stilma, J. S., Bernsen, R. M., 
Arentz, T. G., & Evenhuis, H. M. (2003). 
Refractive errors and visual impairment in 
900 adults with intellectual disabilities in 
the Netherlands. Acta Ophthalmologica 
Scandinavica, 81(2), 123-129.
John Ravenscroft, Ph.D., Senior Research Fellow, 
RIDBC Renwick Centre, University of Newcastle, 
361-365 North Rocks Road, North Rocks, NSW 2151 
Australia; e-mail:<john.ravenscroft@ridbc.org.au>.


Shuffling the Deckchairs: Multi-agency Working and the Continuing Lack of Identification of People with Vision Impairments

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