A Professional’s Guide to Sensory Impairment
by Louise Martinez, Neurological Occupational Therapist at The OT Practice
Introduction
This guide has been produced to explore the role of the occupational therapist in treating clients with sensory impairments. Two case studies have been provided, to give the reader some practical insights and transferable ideas within clinical practice.
Sensory impairments are an often overlooked and invisible health condition in the world of healthcare, where much of the focus remains on diagnosing the clinical priority areas outlined in the Five Year Forward View (with cancer, mental health and dementia as the top three in 2017). And yet the services of occupational therapists, with skills in sensory impairment, are increasingly being requested here at The OT Practice.
There is a higher prevalence of sensory impairment amongst the increasing older population and with more people living longer and healthier lives, sensory impairments are a more common feature of growing older.
Occupational therapists, with their analytical yet holistic approach and wide knowledge base have a thorough understanding of the effects of disability on quality of life. They are uniquely placed to provide the most effective interventions for those with sensory impairments, as their skills lie in understanding the relationship between the person, the environment and the occupation.
The Definition of Sensory Impairment
Most of us are aware of the five senses; sight, hearing, touch, smell and taste. We rely on these every day without much thought. They rely on the collection of external information from outside the body. We also rely on our vestibular systems (balance, and movement), and proprioception, which is our sense of where our body parts are in relation to the environment. These rely on information from within our bodies.
A loud noise might alert us to a potential danger approaching (e.g. a bus coming around the corner). We rely on our sense of touch to tell us whether shower or bath water is too hot, too cold, or ‘just right’. Our senses are a vital defence in protecting us from coming to harm, in addition to bringing us pleasure and enjoyment in life.
Our senses work together in balance, with no one particular sense overriding or standing out. This is known as modulation, which is the ability to rely on our senses to react accordingly to each stimuli, gathering just the right amount of information to communicate back to our brains, eliciting the appropriate reaction.
But what happens when one or more of our senses becomes impaired? Sensory impairment occurs when one or more of our senses are no longer functioning as expected. For example, if you wear glasses you have a sight impairment, if you find it hard to hear or have a hearing aid then you have a hearing impairment. There are obviously different levels of sensory impairments, and it is possible to live quite independently with some degree of sensory impairment with the right skills, aids and or compensatory approach.
Certain groups are more at risk of developing sensory impairment. For example 81% of people who are blind or have sight impairment are aged 50 or above (WHO 11/10/17). People with a learning disability are 10 times more likely to have serious sight and or hearing problems and other sensory impairments.
Some individuals will have more than one impairment, such as dual sensory impairment (combined sight and hearing loss, or ‘DeafBlindness’).
Life choices can become more complicated when sensory impairment occurs on a background of other comorbidities. As outlined in the case study below, had Norman not been diagnosed with Dementia, he and his wife may have moved to a fully adapted bungalow. However, Norman’s need for familiarity and orientation became more of a priority, so they remained in their home.
The Functional Impact of Sensory Impairments. Cognition and Mental Health – ‘The Invisible Person’
Imagine losing your sight suddenly due to illness or injury. The loss of one of our senses can be devastating. But imagine losing your hearing too. The effect of losing one or more of our senses, can result in an individual’s inability to interact with the environment. Even those living with loving and supportive family or carers can experience feeling completely ‘cut off’ from the world.
Helen Keller (a deaf blind 20th century female activist) noted “blindness cuts us off from things, deafness cuts us off from people”. Coping with dual sensory impairment can be very difficult. Signs of sight loss may be apparent to others, with visual cues such as a walking aid, a guide dog. However, hearing loss, or taste, touch or smell impairments are invisible disabilities, and the needs of such a person will rarely be apparent to the wider community.
The stress of living with sensory impairment can put people at risk of depression, adjustment disorder, distrust, anxiety, anger, poor self-image, lack of confidence and self-esteem and feelings of isolation and marginalisation.
Christina Hartman (a writer) has dual sensory impairment. She gives a detailed insight into her experiences in her blog.
“I’ve started to rely more on memory, organisation, and rote, which is hard because I am naturally disorganized and forgetful. I memorize routes that I take through stores, locations of the things that I like to buy, where I put my cell phone. I clean the kitchen methodologically rather than just cleaning what’s dirty. It’s tiring sometimes, keeping so many things in your mind. Earlier this year, I’d have to sleep for nine to ten hours a day just to feel somewhat rested because I wasn’t used to the visual and mental strains. Now, I’m better and getting used to it. I also find myself turning on my cochlear implant more often to feel acquainted with my surroundings. I used to prefer absolute silence, and at some level, I still do. But I no longer feel safe.
It’s sometimes a bit terrifying to even go outside. I feel like since people will assume I can hear, accidents may happen. But I don’t want to become a dependent hermit, so I force myself to go out.”
For more about Christina’s experience: https://www.huffingtonpost.com/quora/what-is-it-like-to-be-dea_b_3056902.html
Approaches used within Sensory Impairment by Occupational Therapists
Sensory impairments such as sight loss or hearing loss are usually permanent, and irreversible. Thus, the approach is most likely to be a compensatory one, rather than a restorative one. A compensatory approach aims to manage, not change, the needs of the person, working within their new limitations to maximise independence.
The impact of sensory impairment differs from person to person. A person’s sensory impairment must be considered in the context of their occupational engagement and ability to function in their own environment. The skill of the occupational therapist is in identifying those activities meaningful to the individual which are adversely affected by their sensory impairment. Therefore the OT would focus on examining roles, relationships, activities of daily living, or accessing the community.
The assessment will consider a demand analysis of the following sensory and perceptual skills:
• Vision - does the activity require vision? (short/long/colour recognition/depth perception)
• Auditory – is hearing necessary? (sounds/tones/volume)
• Gustatory – does the activity require taste discrimination?
• Olfactory – does the activity require distinguishing between different smells?
• Touch – does the activity require fine or gross motor skills / is the ability to recognise different shapes / textures or changes in temperature necessary?
• Are stereognosis / proprioceptive or vestibular skills required?
The management of sensory impairment can be through a range of compensatory approaches. From reorganising the environment, to adapting the task itself or teaching new strategies to enable the client to self-manage their needs. The latter is dependent on cognitive functioning and insight and may not be the optimal approach for someone with cognitive impairment). An OT might, for example, suggest the following approaches to the sensory environment in order to accommodate a client’s specific needs (e.g. adjustments to lighting, temperature, noise level, removal of clutter, BAOT, 2015). It is important to include family members in the entire process of assessment and treatment, as carers will be essential in helping to establish new routines and ensuring successful outcomes in the day to day execution of goals.
Someone living with sudden and irreversible sight loss in later life may experience rapid deterioration in mobility and independence. It is not possible to treat the sight loss, but it may be possible to adapt the task itself. Providing access to a befriending service / volunteer to assist the individual to access the community, can help reduce client social isolation. Individuals are then more able to engage in the activities they enjoyed pre-sight loss.
Other strategies include the Alert Programme (Williams and Shellenberger 1996) a programme for children, parents and teachers to be able to assist the child with sensory processing difficulties recognise how alert they feel. This is a specialist area, requiring an experienced Paediatric occupational therapist.
Assessment of individuals with sensory impairment requires occupational analysis of the whole person, their previous capabilities, occupational roles, interests, choices, belief systems, as well as their current occupational performance.
It is important to consider the realities of possible function according to the stage of any co-existing comorbidities on the sensory impairment (as seen in the case study of Norman).
In the table below, some further examples are given of sensory impairments along with possible causes, impact on function and compensatory strategies which may be used by an OT. It is useful to note that there are some common themes occurring in the impact on client’s lives and function, despite differing causes.
This list is not exhaustive, but aims to provide the reader with an overview.
| Sense | Impairment caused by | Likely Impact on Function | Compensatory strategies used by OTs |
|---|---|---|---|
| Sight | Uncorrected refractive errors (53%) Un-operated Cataracts (25%) Age related Macular Degeneration (4%) Glaucoma (2%) Diabetic Retinopathy (1%) % according to WHO http://www.who.int/news-room/fact-sheets/detail/blindness-and-visual-impairment Optic Nerve hypoplasia Cerebral visual impairment (CVI)Learning Difficulties (Autistic Spectrum Disorder ASD) |
Reduced Communication Social isolation Reduced awareness of environment Safety Risks (kitchen, bathroom) Reduced mobility Falls Difficulty with ADLs (cooking, cleaning, laundry) Curtailment in leisure activities |
Task Modification / Skill Development Small Aids & Equipment (liquid level indicators, cutlery in contrasting colours, tactile stickers (‘bumpons’) to locate microwave/washing machine dials) Assistive Technology (could include infra-red bed sensor lighting to increase independence with night-time toileting for someone who is partially sighted and having falls, or watches with tactile/raised markers, speaking clocks) Audio Books (e.g. Digital Accessible Information Systems or DAISY machine Audio books, talking clocks). Source Guide Volunteers/Befriending/ Care Housing Adaptations (improved lighting, wet rooms, stairlifts, recommendation of specifications, liaison with contractors, review specifications) Teaching new techniques/strategies for ADLs Falls Screening (e.g. trip hazards, mobility, lighting, environment) Signposting to relevant support (RNIB) |
| Hearing | Damage to inner ear (caused by aging, trauma, disease or infections) Wax build up Learning Difficulties (Autistic Spectrum Disorder ASD) |
Difficulty understanding words/speech (especially in a crowd of people) Hearing alarms, telephones, traffic on a road Difficulty concentrating, distraction, boredom Having to ask others to speak more slowly and clearly Needing tv/radio turned up to unsocial volumes Withdrawal from social interaction / social isolation Curtailment of Leisure activities |
Task Modification / Skill Development Assistive Technology (see above) Use of a Communication Passport Assistive Listening Devices Education clients/families/carers Signposting to relevant agencies |
| Smell & Taste | Brain Injury (strokes, traumatic brain injury, hypoxic brain injury) Medications Nasal sinus disease Infections Cancer |
Loss of taste - Inability to experience /enjoy food Loss of smell – inability to taste more complex flavours (grapefruit/steak) Hyper or Hyposensitivity to smells (increased sensitivity or decreased) Reduced appetite Weight loss Depression Social isolation |
Task Modification / Skill Development Assessing meaning of loss for the individual Identifying and addressing risks (e.g. a child with hyposensitivity may seek out stronger smells leading to danger) |
| Touch | Neurological conditions (e.g. MS) Paraesthesia Neuropathy |
Reduced fine motor skills (in hands) Poor temperature awareness (hands and feet) Difficulty dressing/ washing/ cooking/ domestic tasks Difficulty cutting toenails – risk of injury Reduced Mobility/Falls |
Task Modification / Skill Development Small aids and Equipment (e.g. dressing aids) Teaching different techniques by an OT Referral to appropriate agencies (e.g. Chiropodist) Falls Screening |
| Proprioception | Brain Injury Stroke Learning Difficulties (Autistic Spectrum Disorder ASD) |
All movement-walking, running, dancing, picking up a cup, a spoon. Difficulty with spatial awareness Decreased mobility Increased risk of Falls Loss of confidence Depression |
Re-learning ADL tasks e.g. dressing/ washing with an OT Teaching observation of other body cues (e.g. looking at skin to for changed colour to judge correct grip strength) Mirror therapy Environmental changes – ensuring clear pathways, reorganising cupboards, lighting Specific exercises to encourage other senses to compensate (eg. Wobble board practice to increase visual role in balance) |
Case Studies
The case studies below explore the role of an OT with an adult with sensory impairment (Norman), and the role of a Paediatric OT explored by way of contrast in Sally’s case study.
Norman (Adult Case Study)
Norman, aged 67, has age related macular degeneration, worse in his left eye. He has been hard of hearing for some time but this did not affect him until he lost his sight. He experienced total and irreversible sight loss in his right eye after developing temporal arteritis. He became wholly reliant on the residual vision in his left eye, which was sufficient for global navigation, but not much else. As a consequence of the visual loss and hearing loss, Norman’s ability to interact with his environment is now severely limited, and he spends most of his day sitting on the sofa. Previously he was a very active individual for his age, he enjoyed reading and spending time with his grandchildren. His wife became his main carer.
Not long after his sight loss, Norman was also diagnosed with Dementia following short term memory difficulties. His care needs increased as a result.
After the shock of the multiple diagnoses and finding that Norman now needed 24 hour supervision and assistance for most tasks, Norman’s wife decided it was time to move to a bungalow from their much loved family home, which was a two storey property with stairs.
Following a full OT assessment, it was clear that the impact of his sight loss on Norman’s mobility was significant, and he began to experience regular falls at home. His wife now needed to supervise him 24 hours a day.
However, it was identified that Norman remained independent in some areas, such as being able to take himself to the toilet and washing his upper half. He was able to use his long term memory of the layout of his home, (where he has lived for over 30 years) to carefully navigate his way from room to room. As long term memory is often retained the longest in Dementia conditions, and Norman became disorientated and distressed in new environments, the OT assessment helped his wife to realise that staying in their own home was the better option for Norman. This strategy would help to increase his sense of belonging and maintain his orientation for as long as possible.
Whilst his sight loss combined with hearing loss and short term memory loss was causing him to disengage and be socially isolated, OT focused on provision of equipment which would maximise engagement in activities he enjoyed and minimise isolation.
OT input included adapting the home environment with a focus on compensating for Norman’s sight and hearing loss, but factoring in the short term memory loss. Norman’s wife was no longer able to assist him in and out of the bath. The bathroom was therefore fully adapted into a wet room, with a padded wall mounted shower seat in contrasting colours to utilise the limited remaining visual acuity in Norman’s left eye, to help guide him to the seat. Further sensory support systems were also provided, such as, a shower unit with raised tactile symbols, audible adjustment indicators and illuminated LED indicators.
The OT sourced a local builder, and plans were made to convert a room downstairs into a bedroom for Norman for when he is no longer able to manage the stairs. Aids and equipment are provided to enable Norman to regain independence in meaningful activities, such as a DAISY, to enable him to listen to audio books. Advice and guidance was also provided on boot hoists for their vehicle, to enable Norman’s wife to more easily lift the wheelchair in and out of the boot. The OT helped to set up weekly respite for Norman’s wife, allowing her some much needed time for herself, whilst Norman visited a local day centre. Following OT input, Norman and his wife both said they felt relieved they were able to remain in their own home, and manage their day to day life with Norman’s sensory impairments.
Sally (Paediatric Case Study)
Sally, aged 5, was born with total sight loss. She rocks continuously when sitting. She also steps from one foot to the other when standing and walking.
People with full sight are able to receive all of the vestibular stimulation they need during brisk walking movement (which is forward and rhythmic). A blind child may seek vestibular stimulation, but cannot walk with the same confidence and rhythm. Rocking herself gently gives Sally the same vestibular effect, but in a comforting and safe way.
A Paediatric OT would work closely with Sally, her family and her teachers to provide safe ways of enabling Sally to compensate for her sight loss and to regulate her emotions, feel safe and secure at home and in schools. This may involve use of the Alert programme, sensory integration and other strategies such as deep pressure touch input (through massage, weighted clothing, hugging) which stimulates receptors in the skin. This has a calming effect on the brain stem. OT input will ensure that Sally has opportunities to integrate these activities into her daily routine.
A large part of the OT role is to ensure that teachers, family and peers are also educated in sensory impairments, to maximise social inclusion.
Conclusion
It is hoped this guide has provided an overview of the breadth and scope of the role of the occupational therapist in maximising independence with individuals with sensory impairments. Further information and reading is provided in the references list below. To discuss how The OT Practice might assist your clients with a sensory impairment, please contact one of our dedicated Client Managers on 0330 024 9910 who will be able to discuss in detail how we can support you in delivering the best possible service to your clients.
References / Further Information
Communication Passports: [http://www.communicationpassports.org.uk/about/]
Five Year Forward View, NHS England (2017) https://www.england.nhs.uk/five-year-forward-view/
Loss of Smell experience: http://www.bbc.com/future/story/20150811-how-it-feels-to-live-with-no-smell
Practice Briefing, The Role of sensory integration in occupational therapy, April 2015, https://www.rcot.co.uk/practice-resources/occupational-therapy-topics/childhood-adulthood
Royal College of Occupational Therapists, Professional Standards for Occupational Therapy Practice, 2017 – available via RCOT website.
Royal College of Occupational Therapists (2015a) Code of Ethics and Professional Conduct. London: COT. Available via RCOT website.
Royal National Institute for the Blind (RNIB), https://www.rnib.org.uk/who-we-are
Royal College of Occupational Therapists (RCOT) https://www.rcot.co.uk/
Synapse, Reconnecting Lives, Proprioception Factsheet: http://synapse.org.au/information-services/proprioception-fact-sheet.aspx
World Health Organisation (WHO), Blindness and Deafness. http://www.who.int/pbd/en
