Occupational Therapy and Sensory Integration for Students with Visual Impairments (Revised 2025)

Authors: Lisa Ricketts, Occupational Therapist, Texas School for the Blind and Visually Impaired (TSBVI)

Introduction

The author and initial researcher of Sensory Integration Theory used in occupational therapy is Dr. A. Jean Ayers. Her work presents an expansive theory describing how the brain and the body processes, organizes, and integrates the sensations received through sight, sound, touch, taste, smell, body position, and movement.

Students with visual impairment rely on hearing, touch, body position and movement sensations for everyday activities. Normally these activities are directed by vision. Sensory Integration Theory provides a framework to help emphasize and explain the role of all our sensory systems.

Impact of Sensory Integrative Dysfunction

Sensory integration is the organization of sensation for use. Countless bits of sensory information enter our brain at every moment, not only from our eyes and ears, but also from every place in our body. Sensations are food for the brain that provide energy and knowledge needed to direct our body and mind. The greatest development of sensory integration occurs during an adapted response; this is a purposeful, goal directed response to a sensory experience. In an adaptive response, we master a challenge and learn something new. At the same time, the information of an adapted response helps the brain to develop and organize itself. The first seven years of life our brain is a sensory processing machine nourished by having fun through play and movement. The child who learns to organize play is more likely to organize activities of daily living.

If the brain does a poor job of integrating sensations, this will interfere with many things in life. The brain is not processing or organizing the flow of sensory impulses in a manner that gives good, precise information about the body or the world. Learning is difficult and a child often feels uncomfortable and cannot easily cope with demands and stress. If a child is blind or visually impaired this difficulty is compounded when attempting to make sense of his or her world.

Touch

The tactile system processes touch experiences felt through the skin as light touch, firm touch or pressure, static touch, moving touch, temperature, pain, and comfort. There are two primary functions of the tactile system. One is protection and the other is discrimination.

The protective touch function is neurologically bound to the limbic system of the brain.  This system is described as the emotional control center with direct connections to the primal flight or fight responses. The protective function of the skin is reflexive and primarily unconscious with touch sensations automatically categorized into calming, soothing, familiar sensations, or into danger reactions.

The discrimination functions of the skin are conscious, cognitive tasks that are learned through experience. These include touch localization, recognition, and stereognosis. Localization refers to knowing where on the body one is being touched. Tactile recognition is required to learn characteristics of objects such as size, shape, texture, and the weight of items. Stereognosis is object recognition through touch.

Signs of tactile system imbalance

• Reacts negatively to touch, does not like being picked up or hugged
• Does not like being touched and may rub or press on his or her skin after being touched
• Startles easily
• Inability to feel touch immediately and responses are delayed
• Extraordinarily high or low tolerance for pain
• Does not like certain clothing or tags in clothes, and wears clothes for the wrong season
• Does not like band-aids or stickers on skin
• Uncomfortable wearing shoes or socks, or unwilling to walk barefoot
• Does not like brushing hair or teeth, or cleaning and trimming nails
• Avoids certain foods because of texture, or does not chew food well
• Rejects touching messy materials and will not handle clay, mud, or shaving cream
• Washes or wipes hands often
• Uses fingertips instead of the entire hand
• Has a hard time sitting still
• Is poorly coordinated, is a heavy walker, or walks on toes
• Craves touch and may over-touch others or objects
• Doesn’t notice when hands or face are messy
• Doesn’t notice when clothes are twisted, or when feet are not well placed in shoes

Movement

Vestibular processing refers to movement and balance sensations. These are the combined functions of the semicircular canals of the inner ear, basal ganglia, cerebellum and the cerebral motor cortex. This system regulates the feelings of motion such as balance, acceleration, deceleration, starts and stops, direction and rhythm, and creates and stores patterns of movement. The hair cells inside the semicircular canals are activated according to position and movement of the head in relation to gravity. Vestibular processing is likely to be impacted by auditory impairment.

Signs of vestibular system imbalance

• Difficulty maintaining balance and controlling the speed and direction of movement
• Poor balance reactions such as protective extension or righting responses
• Poor spatial orientation and is easily confused by directions
• Fears being upside down or tipped sideways
• Is anxious when feet are not touching the ground
• Is anxious about walking up or down inclines
• Is anxious walking up or down stairs
• Rejects unfamiliar movement activities and is afraid to move backwards
• Is afraid of movement, or is gravitationally insecure
• Gets motion sickness easily
• Is anxious about swimming
• Seeks out gross motor movement and may have a very high tolerance to spinning
• Possible extraneous or non-purposeful movements
• Can’t sit still—craves movement
• Difficulty with self regulation
• Needs to be moving but this may interfere with listening and interacting
• Needs to be moving in order to listen or be attentive
• Needs to jump or spin
• Likes inverted upside down position
• High or low muscle tone—the vestibular system combines with the proprioceptive system to regulate muscle tone

Body Position

Proprioception refers to body position sensation and is required to regulate movement and posture. This system allows us to feel the position of our limbs for motor control and to determine the amount of strength needed for specific actions, or graded force. It is an unconscious feedback system between the muscles & joints of the body and the brain. The receptor stimuli is the bending, straightening, pulling, and compressing of the body’s joints between the bones. Proprioception is neurologically connected to both the tactile and the vestibular system.

Signs of proprioceptive system imbalance

• Has difficulty planning and executing motor tasks for gross or fine motor activities such as getting on or off a bike or riding toy, climbing on/off playground equipment, buttoning clothes, turning on/off a faucet, pouring, etc.
• Has a high need for jumping
• Enjoys hanging by the arms
• Tends to lean on or hang on people or furniture
• Enjoys falling down
• Assumes odd body positions
• Is clumsy and plays roughly
• Breaks toys often
• Grips a pen or pencil too loosely or too tightly
• Has difficulty with fine motor skills for picking up small objects
• Did not crawl much during early development
• Difficulty grading muscle force—muscle exertion is either too much or too little to manipulate objects and perform tasks
• Puts non-food items in the mouth, chews on clothes, or grinds teeth
• May hit, pinch or bite self or others

Intervention

Providing intervention based on the principles of sensory integration theory requires that the Occupational Therapist be able to combine a working knowledge of sensory integration theory with an intuitive ability to gain a child’s trust and create the “just right” challenge. Therapy will involve activities that provide vestibular, proprioceptive, and tactile stimulation, and are designed to meet a child’s specific needs for development.

Activities will also be designed to gradually increase the demands upon a child to make an organized, more mature response. Emphasis is placed on automatic sensory processes in the course of a goal-directed activity, rather than instruction on how to respond. Parent or teacher involvement is crucial to the success of a child’s development and improved sensory processing. The therapist may make suggestions to the parent and teacher about how to help a child in the home and school environment.

Sensory Integration and Sensory Motor Activities

Tactile Play Activities

• If your child or student will not touch materials with their hands and fingers, don’t push. Try letting them touch with a spoon or fork or straw, or try wearing dish gloves to get started. Provide washcloths for frequent hand wiping as needed. If touching bath foam or finger paint is too stressful, put a small amount into a zip lock bag and hold and squeeze the bag. Begin play with dry textures if wet, messy materials are too stressful.
• Try water play outside of demanding situations such as bathing and tooth-brushing. Use various textures of washcloths, sponges, water toys, squirters, water guns. Water plants with a spray bottle. Clean and wipe tables or floors with sponges and a bucket of water. Play with cool and warm temperatures. Help wash dishes in warm water and rinse in cool.
• Fill large storage bins with dry beans or rice and encourage play in the bin with hands and feet. Hide small toys for searching, use cups and coffee cans for pouring, stir with large spoons, and play with funnels and other kitchen toys. Pour beans or other textured material outside on the sidewalk and try to walk across.
• Create feely boxes or bags with a variety of textured materials and various textured toys. Fill with fabric swatches to discriminate, label or match. Fill with items to identify and describe, like wooden puzzle shapes, beads, etc.
• For hand fidgets, keep a fanny pack available with a variety of textured items inside. For squeezing, try stress balls, thera-band, thera-tube, and stretch toys.  Use noisy squeeze toys for play.
• Play dough – use rolling pin, cut dough with safe/dull scissors, practice cutting with knife and fork, use cookie cutters and molds, and hide items to search for (coins, marbles, pebbles, or small toys).
• Try vibration with massagers or vibrating mats or toys, squiggly pens or electric toothbrushes.

Proprioceptive Play Activities

• Move as much as possible! Jump on a trampoline or a mini-tramp. Bounce on yoga balls. Outside, play on all kinds of equipment for supervised climbing and going up and down a slide.
• Any pushing through the hands will help, such as on the tummy over a yoga ball holding body weight through arms and hands. This “prone weight bearing” is very helpful for tactile tolerance, general strength, postural control, and proprioceptive/vestibular input.
• Add weights to items for more feedback. For example, add weight to a cane or pre-cane to help keep it in the correct position and to provide greater pressure feedback. Small size wrist and ankle weights are available – these can be worn for extra proprioceptive feedback and can also be added to other items. Neck and shoulder wraps are available in drug stores, sometimes designed to go in the microwave for heat – these can be used without heating around the neck or held in the lap. 
• Teach simple isometric exercises such as wall push-ups and chair push-ups.  Teach modified push-ups and sit-ups.
• Practice pouring over the sink or outside from heavy containers – gallon and ½ gallon jugs. Practice pouring with pitchers filled with sand or other dry materials.
• The “Zoomball Game” is a toy with a plastic ball strung on two ropes.  The ropes have handles on both ends and the object is to pull arms apart quickly to send the ball to your partner. Arms are spread quickly and closed quickly for a successful pass.
• Roll in a foam pad or quilt for deep pressure games—“the hot dog”, the “burrito”, or the “enchilada.” Use rhythmical touch with hands or roll over with a therapy ball.  Try weighted balls such as a medicine ball (weighted PE ball).
• Throw balls against a wall. Throw to the left and right sides, forward and backward and overhead.

Vestibular Play Activities

• Stationary bike and treadmill exercise. Ride tandem bikes. Help a younger child ride tricycles and bikes with training wheels for left/right integration and reciprocal control.
• Bouncy shoes or “moon shoes”—these are large toy shoes that fit over regular shoes to bounce, jump, and walk with.
• Try as many types of swings as possible—standard playground swings, platform swings, bolster swings, pogo swings (a bouncy and rotational swing) and hammock swings.
• Use rocker boards and spin boards. Both are low to the ground and the rocker board can be used in sitting or standing with support. The spin board is only used for sitting!
• Try a T-stool. Try to keep balance while throwing a ball against the wall.
• Rolling games or races; rolling down or up hills outside. Rolling is terrific for tactile, proprioceptive, & vestibular input and reflex inhibition.
• Practice balancing on one foot. Hop with feet together and hop on one foot.  Jump from one foot to the other. Practice marching, running, or stomping in place.
• Try very low balance beams or tandem walking in a straight line (heel toe, heel toe). Use hand hold support, hold onto a hula hoop, or dowel—add a bean bag to balance on the head for greater challenge. 
• Balance in tall kneel position or half kneel. Toss a ball against the wall while holding balance or keep a bean bag on the head.
• For smaller feet, place feet in shoe boxes to slide along the floor. Try walking with swim fins.
• Directional movement practice—use a heavy wooden chair for sit/stand commands, in front/behind move to the left/right sides, circle the chair, three steps forward/backward from the chair. Add music with slow and fast movements. Combine with Simon Says and Red Light Green Light games. Practice directional commands for facing the front of the room, the back, & either wall. Practice facing north, south, east, and west. Try quick change games for moving from sitting to standing, four point stance to stand on one foot, etc. Practice turning toward sound.

Heavy Work Activities

Heavy work tasks are any activities that require whole body movement and resistance, such as carrying heavy objects or carrying large size boxes; pushing through heavy doors; pushing a grocery or work cart; pushing a laundry basket; pulling a friend in a wagon; helping to move furniture; vacuuming—any activity that requires resistance with movement.

Heavy work activities are thought to provide the longest sensory effect with combined benefits of proprioceptive and vestibular stimulation. Heavy work routines potentially have a calming effect on the nervous system for 4-6 hours.