Into the Blind Spot: Lessons for PTs Treating Patients with Vision Loss

As we trek through our physical therapy programs we cover a seemingly innumerable amount of conditions that we could hypothetically encounter. If your program is anything like ours, we hit on major medical conditions that burden the United States healthcare system but we also become equipped with the tools that allow for us to clinically reason our way through novel encounters. One of those encounters that I find myself thinking about is a patient with a visual impairment. Over my most recent clinical I was presented with a patient that had noticeable visual changes resulting from a stroke. Looking back I feel that my time with this patient was well spent but I definitely have room to grow as a practitioner to treat, educate and empower my patients better. In pursuit to become better practitioners I invite you to join us in this week’s article where we will venture into a different looking world that becomes a reality for our patients with visual impairments.

Visual Impairments

Visual impairments make up a very broad field that encompasses many diagnoses. Physical therapists are general healthcare practitioners by nature and have the potential to be exposed to any number of the conditions that fall under this umbrella term. This could include anything from macular degeneration to diabetic retinopathy to homonymous hemianopsia. For the purposes of this article we want to highlight visual impairments that have unique impacts on the way that you will interact with the patients that have them. Below you will find a short summary for a variety of these conditions that you may encounter in order to help refresh or top off your current knowledge on types of visual impairments.

• Hemianopsia

  • Hemianopsia is a loss of half of the visual field in one or both eyes, most commonly due to damage to the optic tract or occipital lobe, often from stroke or brain injury. Patients may bump into objects or miss visual cues on the affected side

• Diploplia

  • Diplopia, or double vision, results from misalignment of the eyes due to cranial nerve palsies, brainstem lesions, or extraocular muscle dysfunction. Patients see two images of a single object, which may affect depth perception and balance

• Nystagmus

  • Nystagmus is an involuntary, rhythmic movement of the eyes caused by vestibular dysfunction, neurological disorders, or congenital conditions. It often leads to visual blurring, dizziness, and difficulty focusing on objects

• Diabetic Retinopathy

  • Diabetic retinopathy is caused by damage to the small blood vessels of the retina due to prolonged high blood sugar levels. It presents with blurred vision, floaters, or vision loss, often progressing gradually and sometimes unpredictably

• Glaucoma

  • Glaucoma involves increased intraocular pressure that damages the optic nerve, often silently over time. It primarily causes peripheral vision loss, which can progress to tunnel vision and, if untreated, total blindness

• Cortical Blindness

  • Cortical blindness is a loss of vision due to bilateral damage to the occipital lobes, despite normal eye structures. Patients may be unaware of their vision loss and show no pupillary response abnormalities

• Optic Neuritis

  • Optic neuritis is inflammation of the optic nerve, often associated with multiple sclerosis or viral infections. It typically presents as sudden, painful vision loss in one eye with decreased color vision and visual acuity

• Blindness

  • Blindness refers to a complete or near-complete loss of vision, which can result from various causes including trauma, advanced eye disease, or neurological damage. Patients may retain light perception or be entirely without visual input, affecting independence and mobility

Unseen Effects of Vision Impairments

Chronic conditions are like icebergs, what’s visible above the surface is only a small fraction of the total burden. Visual impairments follow the same pattern. While they directly affect visual function, it’s often the less obvious consequences that have a deeper, long-term impact on our patients' health and well-being. Reduced visual input can lead to a cascade of indirect effects, including decreased independence, limited mobility, and reduced social participation. These changes are closely linked with increased rates of depression, anxiety, and even mortality, as patients struggle with the loss of autonomy and freedom in their daily lives⁴. The psychological, social, and economic ramifications of visual impairments are just as significant as the physical symptoms we tend to focus on in therapy, and they deserve equal attention in our clinical reasoning and care planning².

State of the Evidence

In 2017 it was determined that over 7 million Americans are living with some form of visual impairment or blindness¹. Unsurprisingly, our activity recommendations for these individuals are largely the same as for the general population. The catch is that it is generally harder for these individuals to achieve their 150 minutes per week of moderate intensity exercise. In the studies that were included in a 2020 systematic review looking at exercise interventions for people that are visually impaired, it was shown that fall prevention has been the primary focus of research using low intensity interventions such as tai chi and yoga to promote balance and stability. There have indeed been benefits observed with these interventions but they miss out on the physiological benefits that come with higher intensity exercise (sweeting). 

One of the foremost propositions that has been developed to make exercise accessible for people with vision impairments is the ‘Physiotherapy Protocol for People with Visual Impairments (PP-PVI)’. This process involves physical assessment, language selection, design structure and visually impaired language³. The physical assessment portion of this protocol involves our typical examination process that we would conduct at the outset of patient care. Language selection involves identifying terms that are not known to the person with the visual impairment (this is highly variable to each situation and what a person is able to picture based on their life experiences). Design structure and visually impaired language are performed hand in hand as it involves organization of appropriate exercises for the patient’s referral and guided therapy through detailed description and tactile feedback of the chosen interventions^2,3. From this protocol, the participants in studies utilizing PP-PVI were able to improve their confidence in their ability to complete exercises providing a path forward from their sedentary lifestyle.

Clinical Translation

It’s one thing to understand the body of evidence around visual impairments, it’s another to apply that knowledge meaningfully in the clinic. As physical therapists, adapting our approach can make a world of a difference in fostering independence and reducing isolation.

1. Start with intentional communication. During examinations, avoid overly visual language like “watch me” or “look at this.” Instead, use specific, directional, and tactile cues. For example, replace “Step over there” with “Take a big step forward with your right foot” while guiding their hand toward the object. Always check for understanding and invite feedback on whether your instructions make sense in their experience.

2. Integrate the PP-PVI framework. Begin with a thorough physical assessment and ask clear, open-ended questions to understand how the patient's vision affects their daily life. From there, tailor language to match their level of visual understanding, which may differ based on whether their impairment was congenital or acquired. Use tactile modeling, descriptive guidance, and structured repetition to support motor learning.

3. Promote efficiency through structure. Sessions should incorporate consistent strategy using similar description techniques for rapid translation of skills. Using the same equipment setup, mat position, or cue phrases can reduce cognitive load and build confidence. When possible, pair exercises with verbal rhythm or cadence to enhance engagement (think of how “1-2-3 step” can substitute for a visual cue). Document what works and build a routine that allows the patient to take increasing ownership of their rehab.

4. Meet the guidelines creatively. The CDC’s recommendation of 150 minutes of moderate-intensity exercise per week is entirely achievable for visually impaired patients — when we adapt. Caregiver education, partner-based activities, and audio-guided exercise routines are effective tools to incorporate through the course of treatment and to encourage upon discharge. Just as we modify for orthopedic limitations, we can modify for sensory barriers without lowering the bar for our patients’ goals.

Parting Words

Visual impairments may not always be at the forefront of our minds during patient care, but they have a profound influence on how individuals move, perceive, and engage with the world. As physical therapists, we have the responsibility to adapt our methods so these patients aren't left behind. With the right communication, thoughtful cueing, and research-backed strategies like PP-PVI, we can help them build strength, regain confidence, and reclaim independence.

References:

1. CDC. VEHSS Modeled Estimates: Prevalence of Vision Loss and Blindness. Vision and Eye Health Surveillance System. February 5, 2025. Accessed July 19, 2025. https://www.cdc.gov/vision-health-data/prevalence-estimates/vision-loss-prevalence.html

2. Borges Silva M, Novais Shimano SG, Lopes De Oliveira NM. Effects of a Physical Therapy Intervention to Improve the Quality of Life of Visually Impaired People: Development of an Audio–Tactile Exercise Protocol. Journal of Visual Impairment & Blindness. 2021;115(4):329-341. doi:10.1177/0145482x211027491

3. Srivastava N, Pachauria P, Nitesh. Physical rehabilitation of the visually impaired and its implications for tactile modelling. International Journal Of Community Medicine And Public Health. 2024;11(3):1291-1297. doi:10.18203/2394-6040.ijcmph20240634

4. Sweeting J, Merom D, Astuti PAS, Antoun M, Edwards K, Ding D. Physical activity interventions for adults who are visually impaired: a systematic review and meta-analysis. BMJ Open. 2020;10(2):e034036. doi:10.1136/bmjopen-2019-034036

Disclaimer:

We are a current Doctor of Physical Therapy (DPT) students sharing information based on our formal education and independent studies. The content presented in this newsletter is intended for informational and educational purposes only and should not be considered professional medical advice. While we strive to provide accurate and up-to-date information, our knowledge is based on our current academic and clinical rotations and ongoing learning, not extensive clinical practice.