The Brain Body Connection
Cerebral Cortex
Jessica K. Lynn Hatfield, MS, OTR/L, CKTP
Vestibular
Tactile
ASI Intervention
... refers to treatment solely based on Dr. Ayres original principals.
- Fun, novel, and varied tactile media,
- Coupled with multisensory experience including Active proprioceptive , Vestibular data, and Visual & Auditory Information
"Active, individually tailored, sensory-motor activities contextualized in play at the just right challenge that targets adaptive responses for participation in activities and tasks" - Schaaf, 2018
- Gravitational Insecurity (GI)
- Linear movements
- Falling into gravity while feeling safe
- Intolerance to Movement (seasick)
- Proprioceptive activities
- Head turning
- Hypo-responsiveness (vestibular seeking)
- Lots of movement including spinning
- Inadequate vestibular-ocular control
- Target practice while on swings
- Poor postural, laterality, bilateral integration and sequencing
- Somatosensory and vestibular activities that require integration of both sides of the body and postural challenge
Postural and Bilateral Control
- Vestibular spatial
- Target practice in all planes and near and far; ball activities
- Vestibular - postural
- Balance challenges in all positions
- Dynamic postural challenges - moving on unstable surfaces
- Vestibular - bilateral
- Cooperative hand use; hand over hand with effort
- UE and LE coordinated movements e.g. jumping jacks
- Disassociated movements such as dance and sport
- Rhythmic movements such as drumming
Therapist-Child Collaboration
Therapeutic Alliance
Proprioception
Context of Play
Praxis
Just - Right Challenge
- Children seek out “Just right challenges”
- Requires effort but is accomplishable
- Not too hard (unsafe/self esteem effected), not too easy (boring)
- Mastery of each challenge (successful adaptive response) drives development & gives the child a sense of self as a competent being
Sensory Responsiveness
- Over Responsive
- Under Responsive
- Sensory feedback to build body schema
- Sensory feedback to build perceptual awareness of physical and social environment
- Simultaneous sensory processing of body and environment over time
- Building repertoire of action programs and motor skills
- Problem solving future actions
- Selecting and enacting increasingly complex plans
- Organizing time and materials
- Anticipating need for action
- Adapting to unexpected or other directed activities
- Planning and completing task and activities from the beginning, middle to end
- Communicating immediate and future plans
- Projected Action Sequences
- Simple to Complex Praxis
- Stable Person - Stable Object (feedback)
- Moving Person - Stable Object (feedback/feedforward)
- Stable Person - Moving Object (feedforward/feedback)
- Moving Person - Moving Object (feedforward)
Motor Planning (Praxis)
- Imitation-body and face
- Ideation
- Verbal Directions
- Visual: Construction 3D, Copying/Tracing 2D
Clinical Observations
Developed by Erna Blanche
Praxis
Diadokokinesis: Cerebellar function and inform of somatosensory processing
Sequential Finger Touching: Cerebellar and somatosensory processing
Finger to Nose: Cerebellar and somatosensory processing
Eye Movement: Automatic (visual, vestibular, proprioceptive) and Consciously Directed Movement (vestibular function)
Schilder's Arm Extension Test: Vestibular & Proprioception
Supine Flexion: Somatosensory processing
Prone Extension: Vestibular Function
Postural Control: Vestibular, Visual, Proprioceptive Processing
Protective Extension: Vestibular Functioning
Weight Bearing/Proximal Joint Stability: Proprioception, Vestibular
Observe for: Gravitation Insecurity, Tactile Defensiveness, Projected Action Sequence, Bilateral Motor Coordination, Ideation, Praxis
Postural-Ocular - Bilateral Functions
- Righting/Equilibrium
- Postural Control: Prone Extension, Rolling, Co-Cotraction
- Ocular Mechanisms: Head and Eye Movements
- Bilateral integration: Midline Crossing, Directionality
Hypereactivity
Adaptive Response
- A successful response to an environmental challenge
- Child is an active participant
- An appropriate supportive environment can encourage it
- Adaptive responses create changes in the brain
Hyporeactivity
Sour, Spicy, Bitter, Hot
or Crunchy Foods (Alerting)
EASI Tests
Sensory Perception
- Tactile Perception: Localization, Designs, Shapes, Textures
- Proprioception: Position awareness
- Vestibular Perception: PRN, Head Movements
- Visual Perception: Discrimination
- Considering: hearing, taste, smell
- Sourballs
- Salsa
- Cinnamon candies
- Smoked foods
- Jerky
- Chips
- Carrots/celery
Z-Scores help us identify which areas qualify for services
- Popcorn
- Apples
- Crackers
- Pretzels
- Nuts
- Goldfish
- Ginger snaps
- Crunchy cereal
- Lemon drops
- Ice cubes
Motor Cortex
The Ayres Sensory Integration
Fidelity Measure (ASIFM)
A tool for research and clinical purposed to assure the intervention is adhering to the theory and principles originally developed by Jean Aryes
Therapist Qualifications: must have both
- Postgraduate Training (SIPT), 50 hours of SI training
- Supervision, 1 hr/month with mentor who has 5+ yrs of ASI experience
Part I: Safe Environment
Part II: Record Review
- Historical information, Assessment, Goals
Part III: A. Physical Space & B. Available Equipment
- Allows for diverse treatment.
- Equipment that targets vestibular, tactile, proprioceptive
Part IV: Communication with Parents & Teachers
- Parent education
- Parent observation questionnaire
Benefits
- "Open Access" ... FREE
- Accessibility of test materials: 3D Printer and electronically downloaded forms
The Process
- Identify purpose of test
- Identify constructs & how to measure them
- Specify content domains to be measured
- Create preliminary items & try them out
- Field test preliminary items & evaluate them
- Eliminate or revise problematic items
- Pilot test them for item reliability & validity
- Collect normative data & recheck reliability & validity
- Establish norm-referenced scores
The EASI
Sensory Red Flags
Keep the goals in your head,
Activities in your pocket,
And fun in your heart.
-Schaaf (2013)
Over Responsive: Vision
- Avoids eye contact
- Moves/scatters food across plate
- Looks away from food
- Repeated eye blinking / eye watering
- Squinting
- Vomiting
Over Responsive: Smell
- Covers the nose with hand/shirt
- Eye watering
- Turns head away
- Makes a funny face
- Coughing/Gagging to smells
Over Responsive: Tactile
- Lip splays
- Grimacing
- Frequent hand wiping
- Finger splaying
Applications in Feeding
Over Responsive: Taste
- Gagging
- Vomiting to Taste
- Grimmacing/Lip splays
- Shudders
- Granola bars
- Fruit chews
- Dried apricots
- Bagels
- Cheese
- Tootsie rolls
Created as part of Ayres Sensory Integration 2020 Vision
- ASI 2020 - Commemorates Dr. Ayres 100th birthday
- GOAL1: Scholarship, 100 Evidence Based Papers
- 32 papers so far!
- AOTA Systematic Review!
- GOAL2: Affordable assessments, normed internationally
- The EASI!
- GOAL3: International training for ASI treatment
- 100 Countries
- Data Driven Practice
- Explicit Method for tx
Chewy Foods
(Organizing)
Over Responsive: Auditory
- Repeated eye blinking
- Startling reaction to noises
- Covers ears during the meal
Case Study: Caidence
Age: 10:10 Diagnosis: Ehlers-Danlos syndrome
Administered BOT-2 on 12/08/18 (Age at admin 9:10)
Sensory Challenges:
Muscle Fatigue
Hyper Joint Mobility
Gravitation Insecurity
Areas of Concern:
ADLs: Shoe Tying (recently mastered)
Attention: Task completion
Safety: Personal Space, ID unsafe situation
Write:
1 Goal
1 Treatment ax (to address said goal)
The EASI
Information from Kay Toomey's SOS Approach to Feeding Course
Under Responsive: Low Arousal
- Doesn't react to large noxious smells
- Can't locate or loses foods in mouth
- Pockets food in mouth
- Staring into space
- Humming, rocking, self stimulation
- Swallows food whole or barely chewed
- May miss facial expressions
- Starburst
- Gummy bears
- Licorice
- Gum
- Jerky
- Bread crusts
- Postural Praxis
- Sequencing Praxis
- Oral Praxis
- Bilateral Motor Coordination
- Praxis on Verbal Command
- Manual form Perception
- Finger Identification
- Graphesthesia
- Localization of Tactile Stimuli
Under Responsive: Seeker
- Prefers Big and/or complex flavors/tastes
- Appears to have decrease pain responses
- Constantly in motion
- Crashes, climbs everyting (may appear aggressive)
- Grinds teeth
- Seeks spinning
- Over-stuffs food in mouth
- Intense examination of details
Case Study: Nicholas
Age: 6:7
Administered BOT-2 on 11/17/16 (Age at admin 5:7)
Sensory Challenges:
Vestibular (hyper-responsive PRN, aversions to low frequency, Sequencing)
Auditory (poor processing information)
Areas of Concern:
Following Multi-Step Directions
Handwriting
Spillage with Feeding Utensils
Runs into things frequently
Write:
1 Goal
1 Treatment ax (to address said goal)
The SIPT
Sandifer's Reflex: Sign of acid Reflux
- Body arches, head turns to look over right shoulder with associated arm movement.
- Tightens the lower esophageal sphincter to keep food/reflux in.
- Elongates the esophagus for reflux to go back down.
- Space Visualization
- Figure Ground Perception
- Design Copying
- Constructional Praxis
- Motor Accuracy
- Standing / Walking Balance
- Postrotary Nystagmus
- Kinesthesia
Somatosensory Cortex
..... refers to assessments that are based on Dr. A. Jean Ayres’ SI theory such as:
- Standardized Assessments:
- Sensory Integration and Praxis Test (SIPT),
- The Evaluation of Ayres Sensory Integration (EASI) - a new assessment in development as part of ASI 2020 Vision.
- Caregiver Questionnaires:
- Sensory Processing Measure (SPM),
- Sensory Profile (SP),
- Observations Based on Sensory Integration Theory (E. Blanche),
- .... and other scales given with an SI frame of reference in evaluating the results (e.g., Miller Assessment for Preschoolers or MAP)
Assessment
Vision
- Use natural lighting when possible
- Neutral colors (brown, white, yellow) are less excitatory.
- Bright Colors (red, blue, green) are more excitatory.
- Food size
- Scattering food -> use larger food pieces vs power or crumbs.
- Use the "table spoon rule"
- Cut food into recognizable and fun shapes with cookie cutters.
- Place food in or under a cup/bowl, or under another food.
- Clear immediate space
Considerations for Feeding
Tactile
- Hard and dry foods without "give" to them are the best.
- Offer a "tool" to initially interact with.
- Touch through the napkin or from under the plate.
- Use hand UNDER hand.
- Use baggies, have the child wear gloves.
- Play the "shell game"
- Capture and move the puree under a clear bowl
- Mixed Textures
- Teach how to wipe off offending texture.
- Present separate textures first, then mix.
Taste and Smell
- Intensity
- Talk about big taste vs small taste
- Big smell vs small smell
- Present the flavor or smell on washcloth
- Combine with preferred flavor or smell
- Changes in the perception in the session
- Location on the lips, teeth, tongue
- Whole vs chewed
- Add a preferred flavor
- Cover up big smells, wave them away
- Brush or wash tongue off with washcloth
CALMING -> SWEET
ALERTING -> SOUR
MORE ALERTING -> SPICY
MOST ALERTING -> BITTER OR HOT
Oral Motor Ideas
Information from Kay Toomey's SOS Approach to Feeding Course
Resources
- Low-level lighting
- Listen to quiet music with headphones
- Use a soft voice
- Slow down movements and speech
- Quiet corner with pillows or carpeted box
- Have child sit or lie on a vibrating pillow
- Settle child down with heavy hand (firm touch) on shoulder or a bear hug
- Slowly rock in rocking chair or swing on suspended hammock or hanging net
- Sugar-free gum or sugar-free hard candies
- Let child lie down wrapped up in blanket or sleeping bag
- Let child do work in tent made with a blanket
- Sandwich child between two beanbag chairs or large pillows
Calming Techniques
(Ayres, Sensory Integration and the Child, Understanding Hidden Sensory Challenges, 25th Anniversary Edition, 2005)
www.sensoryintegration.org
www.kidfoundation.org The KID Foundation
www.spdnetwork.org Resources for Sensory Processing Disorder Community
www.sinetwork.org Sensory Integration Resources
www.ateachabout.com Diane Henry OTR, FAOTA
ASI 2020 Vision
Pediatric Therapy Network
WPS Sensory Integration Certification
The SOS Approach to Feeding
Therapeutic Listening (Vital Sounds)
Minds in Motion (Louisville KY)
The Inspired TreeHouse
If used appropriately, they:
- Are not distracting
- Improve focus and concentration
- Help students remain alert
- Prevent distractions caused by other nearby stimuli
- Are quiet, so don’t disturb other students
MOVEMENT (VESTIBULAR)
- Doodle while listening
- Shift or squirm in a chair
- Aerobic or isometric exercise
- Sit with crossed leg and bounce leg
- Jog
AUDITORY
- Listen to hard rock or classical music
- Sing or talk to yourself
- Work with radio/TV on
- Work in a quiet room
A Word About Hand Fidgets
Sensory Processing Supports
TOUCH
- Twist hair
- Rattle coins in pocket
- Drum fingers on table
- Pet a cat or dog
- Receive a massage
- Take a cool shower or warm bath
- Play with phone cord while talking on phone
Acknowledgments
The following slides were adapted from Williams & Shellenberger’s program,
The Alert Program: How Does Your Engine Run?
VISUAL
- Watch a sunrise/sunset
- Watch an aquarium
- Watch a fireplace
SENSORY-MOTOR PREFERENCES
FOR ADULTS
Model based on research by:
- Lucy Jane Miller, PhD, OTR
- Sharon Cermak, EdD, OTR
- Shelly Lane, PhD, OTR
- Marie Anzalone, ScD, OTR
- Jane Koomar, PhD, OTR/L
- Beth Osten, MS, OTR/L
ORAL
- Bite nails
- Suck on hard candy
- Drink coffee
- Chew gum
- Smoke
Sensory Processing Disorder (SPD)
Thank you to the brilliant occupational therapists
for their work and dedication, and for giving us
permission to share their resources in this
presentation:
Lucy Jane Miller
Erna Blance
Shay McAtee
Carol Kranowitz
Sue Trautman
Laura Barker
Bonnie Hanschu
Mary Sue Williamson
Sherry Shellenberger
Rosanne Schaaf
We are also grateful for Dr. A. Jean Ayres for her pioneering work in the theory of sensory integration.
- does not become more organized after receiving intense sensory input
- has difficulty waiting or taking turns – does better with cognitive rather than sensory input
- tends to talk all the time, impulsively interrupting
- craves novelty and activity that is not necessarily related to specific sensations
- cannot stop impulsive behavior regardless of the sensory input
ADHD
Sensory Integration vs. Inattentive ADHD
- looks more organized after receiving intense sensory input
- touches, pulls, and/or pokes people or objects; seems to need more tactile input than most children
- more patient if given appropriate sensory input while waiting
- craves activity that is specifically related to sensation (usually movement and sometimes muscle input)
- can stop impulsive behavior if sensory input is sufficient
SI
Nicholas
*attend
*demonstrate knowledge
*learn
*interact with others
*move
*self-esteem
*express feelings
- Midmorning healthful snack
- Bright lighting
- Increase air circulation with fans or by opening windows
- Move briskly
- Speak quickly
- Play loud, fast-paced music
- Let child run in place or jump
- Encourage child to swing fast during recess
- Splash cool water on face or neck
- Sip from water bottle filled with ice water
- Run errand in building
- Use “ball” chair
- can get started but difficulty following through – forgets directions. No motor component involved
- often forgets or gets lost in the middle of a routine
- interested but makes careless mistakes
- initiates but doesn't stick to activity
ADHD
Alerting Techniques
Sensory Integration vs. Inattentive ADHD
- difficulty processing directions so doesn’t follow through due to motor planning issues
- knows the routines but is impossibly slow
- fatigues and appears lazy, bored
- in a daze, seems uninterested
- doesn’t initiate activities
Sensory Integration...
SI
what we:
*see *hear
*taste *touch
*smell
*how we feel our bodies
*how we feel movement
Interaction with environment and practice
Praxis Patterns
Praxis is the ability by which we figure out how to use our hands and body in skilled tasks like playing with toys; using tools, including a pencil or fork; building a structure, whether a toy block tower or a house; straightening up a room; or engaging in many occupations."
- Ayres, 1985
"Praxis is the basis for dealing with the physical environment in an adaptive way." - Ayres, 1985
It is a cognitive perceptual function greatly contributing to learning.
Children with dyspraxia also exhibit executive function disorders.
- Somato-Praxis: Body/Objects as tools, accessing affordances.
- Visual Praxis: Utilizing space
- Ideational Praxis: Initiating actions
- Praxis on Verbal Command: Interactions with people
Introduction to ASI Theory
- “The spatial and temporal aspects of input from different sensory modalities are interpreted, associated, and unified.
- The brain must select, enhance, inhibit, compare and associate the sensory information in a flexible, constantly changing pattern: in other words, integrate it."
- Contributes to
- Arousal, alertness and attention
- Cognitive, motor and praxis skills
- Emotional regulation
- Social communication and interaction
- Organization of behavior in time and space
Vestibular, Bilateral Integration & Sequencing Pattern
- Gravitational Insecurity
- fear of moving head through space, Backwards, Passive, When there are heights or visual cliffs
- Hyper-responsiveness to Movement
- “seasickness"/Nausea, Pallor, Vertigo, Headaches
- Hypo-responsiveness to Movement
- Seeking Movement
- Vestibular-Ocular Responses
- Compensatory Eye Movements (Eyes don't stabilize during head turns - Vestibulo-Ocular Reflex), High/Low PRN
- Postural Control
- Static Postural Control
- Active Postural Control: Anticipates movement & Reactive postural control
- Bilateral Motor Control: Crossing midline, rhythmic movements, cooperative hand use,
Vestibular
Observations (Proprioception)
Semicircular Canals
- F1. Tone and Joint Alignment
- Jt hypermobility, decreased tone, poor jt alignment
- F2. Behavioral Manifestations
- Pushing, overactive, crashing, falling, running
- Correlates with SPM bumping and pushing
- F3. Postural Motor
- Decreased PC, tendency to lean, inefficient grading force, inadequate wt bearing, inefficient ankle strategies
- Correlates with SPM body awareness and SWB
- F4. Motor Planning
- Decreased feedback planning, decreased feedforward planning, overly passive
- No correlation with SPM body awareness, weak correlation with KIN and SWB
Blanche, Bodison, Chang & Reinoso (2015)
(Ayres, Sensory Integration and the Child, Understanding Hidden Sensory Challenges, 25thAnniversary Edition, 2005)
1
Sensory integration is...
- “the organization of sensory input for use... Through sensory integration, the many parts of the nervous system work together so that a person can interact with the environment effectively and experience appropriate satisfaction”
- An unconscious process of the brain
- Organizes information detected by one's senses
- Gives meaning to what is experienced
- Allows us to act or respond to the situation
- Forms an underlying foundation for learning and behavior
- Positioned at right angles from eachother
- Perceives changes in rotational movement
... refers to the principals developed by Dr. A. Jean Ayres as a result of her extensive research
Introduction to ASI Theory
Somatosensory Pattern
Proprioception Difficulties
- Moving
- Coactivation of muscle synergies
- Graded Movements
- force
- direction
- Stabilizing
- Readiness to move
- Midrange control
- Head, trunk, limbs, fingers
- What do we do when it's too heavy
- Breath-Holding: for postrual stability -> increase sympathethic
omeostasis
Thalamus
lfaction
H
O
M
E
2
Limbic System
emory
Considerations:
- How does this make you feel? (uncomfortable / skilled)
- How does this effect your attention?
- Did anyone laugh while you performed activity?
- Did anyone around you try to correct you?
- If you had to perform under these demands all the time would it effect your participation level?
Dyspraxia/Motor Planning:
Write your first and last name using the following letter substitutions within 30 sec:
A=B C=D E=F G=H I=J K=L M=N O=P Q=R S=T U=V W=X Y=Z
Together:
Groups:
- Tactile
- Visual Motor
- Vestibular / Proprioception
Experential Activites
Tactile Difficulties
- Responsiveness/Reactivity
- Tactile defensiveness
- Registration Problem
- Discrimination - Perception
- Tactile localization - fingers, face, body
- Tactile shape, size, weight perception etc.
- Stereognosis
- Graphomotor abilities
Somatosenory Pattern
motion
The "Traffic cop" for incomming information
Post Rotary Nystagmus (PRN)
Triggered by a change of direction
- Location: Inner ear
- Attached to cochlea
- Perceives
- What: Speed, Rhythm/ Smoothness
- Where: Direction
If Velocity is constant, cilia return to resting position
Ability to distinguish & interpret sensory inputs
Midbrain
Sensory Discrimination & Perception
Per Rotary Nystagmus: During rotation,
perpherial reflex, for stabilization
Associated with arousal, movement, vision hearing etc.
Vertical
- Sensory Reactivity/Modulation: Regulation of arousal and behavioral responses to sensory input
- Sensory Processing: (Umbrella term) Receptor + CNS function
- Sensory Registration: CNS “notices” input
- Bilateral integration & sequencing: Coordination of the two sides of body to perform synchronized and sequential movements
- Praxis: Ability to conceptualize and organize novel action
- Interoception: inside the body
- Splinter Skills: Skills that are partially developed skills as a result of functional demands.
As long as there is gravity these receptors are activated
Good Sensory Integration allows the information to flow easily and reach their destination quickly.
When there is a dysfunction some information gets tied up in traffic. The part of the brain that is supposed to get this information can't integrate the delayed information to do it's job.
An accident or illness that results in significant trauma to the brain are circumstances that usually lead to poor sensory processing. In most cases of sensory integration dysfunction, there is not damage to the structure of the brain or receptor.
Terminology
Horizontal
Pons
3
Sensory Integration Dysfunction
Ritcular Activating System
Brainstem
Cerebellum
Involuntary Bodily Functions
(breathing, heart rate etc)
Medulla
- Awareness of movement (rotational and linear)
- Awareness of direction/position in space (with auditory information)
- Critical for maintaining postural control (muscle tone - antigravity)
- Critical for using visual information
Coordination & Smoothness of movement
Somatosensory
Spinothalamic Tract
Proprioception
Location: muscle fibers, tendons, ligaments
- Perceives:
- What: Touch
- Where: Location on skin
- Contributes to body scheme
- Required for learning and praxis
- Senses:
- Pain
- Temperature
- Crude touch
- Body's back up plan for touch
- Perceives
- What: Force/Pressure
- Where: Joint Positions
- Uses info from muscles and joints
- Contributes to Awareness of body and limb position
- Required for Kinesthesia & Stereognosis
- Part of somatosensory
- Related to muscle tone
- Functional tone & joint stability
- Different from Exteroception
- touch, deep pressure, pain, temp.
Muscle Spindle
Sense of
position/movement
Dorsal Root Ganglion
Sensory Information enters the CNS
(Afferent Fibers)
Gray Commissure
(Gray Matter)
Ventral Root Ganglion
The Spinal Cord
Motor Movements
out to the PNS
(Efferent Fibers)
The Central Nervous System
Sense of Tension
Dorsal Column Medial Lemniscus Tract