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Development of Low-Cost Tactile Neuroanatomy Learning Tools for Students

With Visual-Impairment

Article  in  Journal of Undergraduate Neuroscience Education · June 2019

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 The Journal of Undergraduate Neuroscience Education (JUNE), Spring 2019, 17(2):A153-A158

ARTICLE
Development of Low-Cost Tactile Neuroanatomy Learning Tools for Students
With Visual-Impairment
Giovanne B. Diniz & Luciane V. Sita
Department of Anatomy, Institute of Biomedical Sciences, University of São Paulo, Brazil 05508-000.

Visual impairment is the most common form of disability in fabrics. These tools were then employed in an
the world and results in major challenges to the education undergraduate class of physical therapy, speech therapy
and employment of affected individuals. It is important, and occupational therapy students that included a student
therefore, to provide the best possible higher education for with visual impairment. The use of tactile tools allowed full
these individuals, not only providing the same access to integration of the student, who was able to participate in
theoretical contents but also training them for their future hands-on classes with her peers. We anticipate that the
work environment. The reliance of neuroanatomy teaching ease of fabrication and the low cost may allow this
on visual material creates a set of challenges for educators, experience to be replicated in the instruction of
a situation that is only worsened by the lack of specific neuroanatomy in undergraduate neuroscience programs at
neuroanatomy teaching tools for students with visual other institutions.
impairment. To overcome this problem, a set of tactile tools
for neuroanatomy education was prepared using low-cost Key words: gross anatomy education; blindness; visual
materials such as hot-melt adhesive, pins and easily found impairment; cooperative learning; inclusive education

The anatomical sciences have long relied on visual et al., 2000; Goldreich and Kanics, 2003, 2006; Wong et al.,
representations of animal structures, from the 2011), and their hand cortical representation allow them
groundbreaking vivisection works of Vesalius (1543) to the better spatial perception through touch (Heller and Gentaz,
modern virtual humans that can be dissected on a 2013). Other authors have suggested that tactile material
touchscreen table (Fyfe et al., 2013). The study of the use is beneficial in science classes, with students reporting
nervous system is no exception, with modern classes of higher levels of interest when those tools are employed
neuroanatomy often relying on heavily-illustrated textbooks, (Jones et al., 2006; Mulloy et al., 2014). Although there is
anatomy atlases, medical imaging, hands-on classes with specialized equipment that can create textures, this
cadavers and the analysis of central nervous system equipment is often expensive (Mulloy et al., 2014). It is
sections on the microscope or in digital repositories (Ramos possible, however, to create similar tools using craft
et al., 2008; Grisham, 2009). Although this multitude of materials (Mulloy et al., 2014). In this work, we report the
visual tools is extremely beneficial for educators and process of development of low-cost tactile tools designed to
students alike, it can easily exclude students who are teach core concepts of neuroanatomy using craft materials.
visually impaired or blind, since most of the available
didactic tools are designed for sighted individuals. MATERIALS AND METHODS
According to the World Health Organization, visual We report the development of two sets of tactile materials
impairment is the most common type of disability in the world for neuroanatomy. The first set consisted of pre-existing
(Pascolini and Mariotti, 2012). Although refractive errors fixated brains (whole or dissected) that we covered in
and cataract account for the majority of those cases, about texture-rich materials. Authorization to perform this work
1.4 million people globally 14 years of age or younger are was granted by the Brazilian National Committee for Ethics
blind (Pascolini and Mariotti, 2012). There is, therefore, a in Research. The second set consisted of printed electronic
significant number of individuals who will spend their lives drawings showing specific structures and areas onto which
unable to take part in sight-dependent activities. In Brazil we glued texture-rich fabrics.
alone, Salomão et al. (2009) report that 0.41% of children In the first set, we prepared five fixed human brain
11-14 years of age are visually impaired despite refractive specimens by coating the main gross anatomical features
correction. When this data is crossed with the national including several neocortical hemispheres and one
demographic census, it indicates that over 70,000 school brainstem and cerebellum. All brains used belong to the
children had severe uncorrectable sight problems in 2010 Department of Anatomy of the Institute of Biomedical
(IBGE, 2010). Sciences and were donated by the São Paulo Death
We sought to develop assistive tactile graphical Verification Service of the Medical School of the University
illustrations and three-dimensional models built from fixed of São Paulo. The brains were fixed using Giacomini’s
brains that could be used in the classroom to improve Method (Robson, 1882). The brain stem was cut just below
learning and integration of students who are visually the pyramidal decussation and just above the cerebral
impaired or blind. It has been reported that individuals who peduncles, and the cerebellum was connected to it by all
are blind have heightened tactile discrimination (Van Boven cerebellar peduncles. In this specimen, we placed large
JUNE is a publication of Faculty for Undergraduate Neuroscience (FUN) www.funjournal.org
 Diniz and Sita Neuroanatomy learning tools for visually impaired students A154

Figure 1. Three-dimensional tactile tools developed and used in class. Pictures of the three-dimensional tools after tactile material
assembly were taken with a digital camera. A) cerebellum with the primary fissure outlined with pins; B) Lateral view of a human brain
hemisphere where the main sulci studied are demarked by large head pins; C) Another lateral view of a human brain hemisphere with
some of its gyri covered by fabric; D) Medial view of a human brain hemisphere where several structures are outlined, including the
diencephalon, gyri, and the corpus callosum.

head pins along the primary fissure in the anterior surface of anchoring the fabric to the wall of the adjoining gyri (Figure
the cerebellum and along the posterior fissure in the 1C). Fabrics of different colors and textures were used,
posterior surface of the cerebellum (Figure 1A). Care was including velvet, polyester microfiber, non-woven
taken to guarantee that the pin head protruded over the level polypropylene fabric, felt, tulle, terry cloth and jute cloth.
of the surrounding tissue and that the pin was deep enough When possible, the pins protruded slightly over the level of
in the tissue, so it would not move upon light pressure. A the fabric to indicate the sulcus position relative to the gyrus.
similar procedure was performed in a brain hemisphere to The fourth specimen was also a brain hemisphere, but the
outline the central and lateral sulci and the preoccipital notch marked structures were in the medial face. The
(Figure 1B). Whereas the sulcus was too deep to allow hypothalamus, thalamus, corpus callosum, cingulate gyrus
vertical pin placement, we placed the pin in an angled and straight gyrus were among the structures coated with
position in the adjoining gyrus. fabrics (Figure 1D). To hold the fabric over the
The third specimen was a brain hemisphere designed for hypothalamus, we placed three large head pins over the
the study of the main gyri. To coat the hemispheres, thin mammillary body, the infundibulum, and the anterior
layers of fabric were cut to size slightly larger than the gyri commissure. These pins had the double purpose of holding
and were fixed on the brain using small head pins along their the fabric and marking these anatomical landmarks. A
whole extension. The pins were placed slightly inclined, protruding line of small head pins was placed between the
 The Journal of Undergraduate Neuroscience Education (JUNE), Spring 2019, 17(2):A153-A158 A155

horizontal sections, and another plate illustrating horizontal

sections of the spinal cord at different levels (Figure 3).
These plates contained only the structures that were part of
the class syllabus, to avoid overwhelming the impaired
student during her process of creating mental images
(Hatwell et al., 2003). To generate the brain illustrations,
coronal and horizontal sections were prepared from
formaldehyde fixated brains. We cut the whole brains in the
frontal or horizontal planes with a sharp knife. We acquired
digital photographs from six different rostrocaudal levels and
three different dorsoventral levels. The pictures were then
opened in Adobe Illustrator CC 2017 (Adobe Systems; San
Jose, CA, USA) and we drew the outline of each section.
Only structures included in the course syllabus were drawn
for the sake of clarity. The illustrations were composed of
two parts. On the left side, structures were colored to
facilitate the identification and fixation of fabric to the
structures. On the right side, the corresponding structures
were outlined and labeled. The number of structures
labeled varied from six to seventeen in the coronal
illustrations and three to twelve in the horizontal illustrations.
To prepare the spinal cord illustrations, we photographed
myelin-stained human spinal sections under a microscope
and repeated the procedure described above.
Once the illustrations were ready, they were printed on
A4 paper and fixed on foamcore plates to increase their
durability. Hot-melt glue was used on the outer margin of
the drawing and around the ventricles to create a tactile
margin. Pieces of several types of fabric were cut out with
a pair of scissors or a box cutter and glued to the drawings
with hot-melt glue. Figure 2 illustrates the tactile coronal
drawings and Figure 3 shows the horizontal and spinal cord
drawings.

RESULTS AND DISCUSSION

We deployed tactile material in the hands-on laboratory
activity that followed all the expositive gross anatomy
classes. The class was composed of physical therapy,
speech therapy, and occupational therapy undergraduate
students. Among the students there was a female
individual, age-paired to her peers, who is blind. In each
hands-on laboratory, there were prosected specimens of the
brain and the rest of the body and stereo-microscopes with
myelin-stained spinal cord sections, selected depending on
the content of the previous class. Both cadaveric and tactile
materials were distributed on steel dissection tables, and the
students were divided into groups of up to eight students,
including the student who is blind. All groups did turns on
the different tables with the tactile materials described
Figure 2. Pictures of the drawings of frontal sections after tactile above. The student who is blind was allowed to stay as
material assembly. Pictures were taken with a digital camera. much time as necessary interacting with the tactile
Structure labels are in Portuguese because these are the plates materials. All tactile material was also made available in the
used in classroom. English versions of the same plates are laboratory for all students to review after class. Following
available upon request from the authors. our anatomy laboratory policies, all laboratory users wore
latex or nitrile gloves while handling the specimens but
thalamus and the hypothalamus to indicate the sulcus. A
remained with bare hands while using books, models, or
flat head pin has been put over the pineal gland to indicate
non-biologic materials. Figure 4 illustrates the student who
the position of this structure.
is blind interacting with the tactile material during the class
The second set consisted of six plates illustrating coronal
and highlights the differences in texture among the several
sections of the brain (Figure 2), three plates illustrating
brain areas illustrated.
 Diniz and Sita Neuroanatomy learning tools for visually impaired students A156

The tactile material was effective in engaging the student when sliced and the relative shape and position of the
who is blind during the hands-on classes. The use of latex ventricles, several subcortical structures (e.g., caudate
gloves did not impair the tactile perception of the student nucleus, putamen nucleus, globus pallidus, hippocampus)
who is blind which is consistant with previous research on and the thalamus and hypothalamus.
the effect of wearing gloves on tactile perceptions (Gibson To evaluate the teaching efficiency of the tactile material,
and Craig, 2005; Thompson and Lambert, 1995; Hatzfeld et the student who is blind performed theoretical and practical
al., 2018). The cerebellum specimen allowed her to examinations. The decision to include this student in all
successfully identify the anterior, posterior and testing activities was guided by the work of Golub (2006),
flocculonodular lobes, as well as the primary and posterior which describes a higher acceptance by the peers when the
fissures. The lateral hemispheres allowed her to determine same performance is expected from colleagues with visual
the overall outer structure of the brain, including the lateral impairment. For the theoretical component, the examination
and central sulci, and the precentral, postcentral, inferior was applied on a text editor and a text-to-speech software.
frontal and superior temporal gyri. The student identified the Care was taken to ensure that no complex formatting
main divisions of the diencephalon, anatomical landmarks of elements (such as tables and diagrams) were used in the
the hypothalamus and inter-hemisphere connecting examination, as assistive software often incorrectly conveys
structures in the medial hemisphere. Using the tactile this kind of information. During the practical component, the
plates, the student could study the anatomical divisions of student was free to explore the anatomical specimen and
the central nervous system, the overall shape of the brain the tactile drawings. When ready, a member of the teaching

Figure 3. Pictures of the drawings of horizontal sections after tactile material assembly. Pictures were taken with a digital camera.
Structure labels are in Portuguese because these are the plates used in classroom. English versions of the same plates are available
upon request from the authors.
 The Journal of Undergraduate Neuroscience Education (JUNE), Spring 2019, 17(2):A153-A158 A157

classmates during class. As pointed out by Fichten et al

(2012) and Golub (2006), colleagues are important
facilitators for individuals with disabilities in order to
overcome academic and workplace barriers. Furthermore,
allied health professionals often must work with people with
several types of disability, including partial or complete loss
of sight. By directly interacting with the student who is blind
during the hands-on class, the other students were able to
follow closely how a person who is blind interacts with the
world, and in this case, with the tactile neuroanatomy
material. Braille captions may be necessary, however,
depending on the available time for hands-on class activites
and the interpersonal dynamics of the students in the class.
Bryan (1950) has long described that lack of engagement
or active learning is a significant problem for students with
visual impairment or blindness in biology and related
science laboratories. Though some teachers solve this
issue with private classes (Womble and Walker, 2001), the
current best practice is adaptating the study material in a
way that promotes more effective learning (Mastropieri &
Scruggs, 1992). With that in mind, schools have
implemented the use of 2D and 3D models in biology
classes to support the learning of students with visual
impairment or blindness (Reynaga-Peña, 2015). Many 2D
models for the Blind were developed by American Printing
House (n.d.) and are available online for printing. These
images do not, however, cover the knowledge taught in
neuranatomy classes in higher education.
Another design concern we had during the material
development was the overall cost, avoiding the use of
embossing printers and 3D printers, which is still
inaccessible to many educational institutions in developing
or low-income countries (Ishengoma and Mtaho, 2014). In
this work, the overall cost of specimen and plates
preparation was approximately USD$25, and the only
Figure 4. The use of tactile materials in the classroom. Pictures of required hardware was a common printer and a hot-melt
the tactile materials in the classroom were taken with a digital glue gun. The development of tactile neuroanatomy
camera. A) The tactile materials allow for visually impaired and teaching material as described here, therefore, is virtually
blind students to identify several key subcortical structures; B) universal and can be used regardless of pre-existing
Higher zoom of a tactile plate to highlight the differences in
infrastructure.
composition, roughness, and height.
To conclude, highlighted here is the necessity for better
tools to teach neuroanatomy to students who are visually
staff directed the student’s finger to the structure being
impaired or blind. In the experience described in this work,
asked, and the student named that structure. The teacher
the use of tactile neuroanatomy materials was a successful
noted the answers and graded the examination along with
way to engage a blind student in hands-on class activities
those of her peers. Her performance was similar to her
and to integrate the student with her peers. We have
sighted colleagues. The class mean ± SD score was 6.3 ±
described an approach to create low-cost, easily-assembled
1.7, and the student who is blind attained 6.2, indicating that
tactile materials that are universally accessible to all
she was able to acquire a similar amount of content during
students including those with visual disability. We hope
the class period. This is suggestive that the student was
these tools can be reproduced and expanded upon in other
able to create mental images using haptic perception, and
environments such as in an undergraduate neuroanatomy
later evoke this mental image to correctly answer the exam
course. As the number of neuroscience majors continues to
questions (Hatwell et al., 2003).
grow, educators will need resources and skills to educate
An important consideration to be made was the design
diverse student populations, including those with visual
choice not to make the structure captions available in Braille.
impairment.
During the designing period of the tactile material, we
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