Thursday 6 November 2014

Gross motor & Fine motor




In Bangalore, a diagnosis of autism, PDD-NOS, or ADHD translates into occupational therapy (OT) services for sensory integration (SI). There is no denying that sensory integration is mostly practiced by occupational therapists throughout the world. However, many physiotherapists (PT) like myself also choose to train in SI.

In most Western countries, there is a distinct  division of services between  OT and PT. The PT provides services that focus on gross motor activities, address the larger muscles of the body, and mostly the trunk and legs. The OT works on fine motor, smaller muscles of the body, and mostly the trunk and arms. Inevitably, there is an overlap between both services; it is not unusual to see an OT and PT working together to treat a patient and address different goals during the same session.

The concrete reason for my preceding explanation is that fine motor progress cannot be achieved without first addressing the larger muscles of the body that include the trunk. Our trunk forms the foundation for working of the arms and the legs. Weakness of abdominals and/or the back extensors results into an array of problems in posture, postural control, balance, coordination, and fine motor tasks such as writing/cutting/coloring.

We need a good core strength of the trunk  to stay upright, alert, and ready for movement skills such as throwing/catching/kicking a ball. Core strength also plays an important role in climbing playground equipment and keeping balance on uneven terrain. Good postural control is required for all activities ranging from reaching for an object on a shelf to writing efficiently on paper.

Without adequate abdominal muscle strength, speech and respiration are compromised. In my clinical practice, I have observed improved speech, relief of constipation if any, and increase in stamina due to emphasis on improving abdominal  tone and strength.  Activities designed to improve upper body strength result into better writing skills and coordinated use of both arms and hands.


In summary, gross motor precedes fine motor.

Tuesday 1 July 2014

Mirror Neurons


Mirror neurons are specific  nerve cells in the premotor cortex area of our brain. The mirror neuron system (MNS)  is known as a trimodal system that responds to motor, visual, and auditory stimuli.  These neurons specialize in  imitation learning, action understanding, action recognition, and action execution.  They were first discovered in brains of monkeys and recent research supports their presence in human brains too.
The MNS provides us a way of understanding actions performed by other people around us. It  responds to not only observation of a task, but also to an audio-visual representation of the task. It would fire when you hear the sound of ripping a paper or hammering a nail, and also fire when you read about these actions. The MNS allows children to learn by observation, as well as mapping other s’ actions onto their own actions and language. Therefore the MNS is involved in aspects of learning language, communication, and social skills. Researchers believe that children with autism have  dysfunctional mirror neurons.

Implications of the Mirror neuron system
Throughout  years of clinical experience, it has been my observation that children perform better in therapy when paired with another child.  Some activities such as climbing, jumping, pushing heavy loads etc.are best performed with a partner rather than one-on-one therapy. Mere presence of another child becomes a motivating factor for participation in therapeutic activities.
 My clinical assumption is that the mirror neuron system receives an opportunity for stimulation. However, the activities should be more or less structured and not overwhelm the child.


Children with ASD become socially isolated since they are not able to interact appropriately with peers  and/or they are shuffled between a range of activities.  Just like any other therapy, I would suggest parents to reserve some time for social interaction 1-2 times per week. You can start with inviting a playmate for your child  40-45 minutes at home or in a quiet park. Encourage sharing of toys, taking turns, eating a snack together. Social interaction plays a pivotal role in development of language, communication, imitation and  learning.

Tuesday 27 May 2014

Sensory Integration Dysfunction




In the last post, I had discussed about the various senses and the definition/meaning of SI.  When integration of sensory information from both-within the body and from the external environment  does not occur appropriately,  it results into SI dysfunction or sensory processing disorder.  Apart from autism, this dysfunction is  seen in many other diagnoses such as attention deficit disorder, developmental coordination disorder, dyslexia,  speech disorder, and traumatic brain injury.
If a child exhibits any of the following symptoms, he/she needs to be evaluated by a qualified clinician.
       Speech delays, echolalia, poor social skills.
       Playing with a limited variety of objects.
       Toe walking.
       Mouth open.
       Hand flapping/constantly moving/looking at spinning objects.
       Poor eye contact.
       Lack of hand use.
       Eating/feeding problems.
       Serious toileting problems.
       Sensitivity to loud noises.
       Attracted to rhythmic sounds such as alarm clock, machines etc.

The above symptoms are suggestive of sensory processing difficulties;  the child may fall in any one of the following categories—
Under processing  of sensory information—the child may present to be very passive and poorly interacting with people or objects in the environment.   OR
The child would not be receiving adequate sensory input and hence seeks information by touching /pushing/crashing into objects without meaningful exploration. The child may also run around aimlessly to seek vestibular information.
Over reacting to sensory information—is expressed as being sensitive to loud noises such as sounds of the grinder and pressure cooker, being defensive to touching different textures, being fearful of moving surfaces such as swings.
Some children may fluctuate between being under responsive and  being over reactive.
Modulation deficit—the child  tolerates  a very narrow bandwidth of any type of sensory information. Such children move very cautiously, become fearful when the feet leave the ground, refrain from handling objects, and minimally use their hands to hold objects. They avoid interacting with toys or objects.
Discrimination deficit—is characterized by decreased ability to differentiate between different textures to touch, sort visual information, and lack of appropriate muscle force for a particular activity.
A detailed history and careful observation of the child will reveal the prĂ©cise underlying issues in the sensory systems. Any  dysfunction interferes with development of adequate muscle tone, eye movements, posture, balance, and motor skills.  Deficits in one or more of these areas hinder speech/language, self-regulation, and socio-emotional skills.



How does SI  treatment work?
SI focuses on remediating the dysfunctional sensory processing. SI is practiced in a way such that the child is an active participant in a sensory rich environment.  The purpose is to provide optimal input through the sensory channels so as to facilitate engagement /learning, and ultimately  obtain an adaptive response from the child. Activities are child-directed and conducted to provide “just the right challenge” to the child. Activities are graded to allow success without causing frustration. Active participation leads to building new connections in the brain. 

It is important to remember that  problems exhibited by the child become magnified in crowded areas such as classroom, school gym,  and cafeteria. Additionally, the child’s performance also varies in different environments.


What therapists have believed since decades about sensory integration  issues as related to autism is now increasingly demonstrated by research. 
 Brain imaging may illustrate why individuals with autism often overwhelmed by information coming in from different "directions".
http://www.autismspeaks.org/science/science-news/brain-scans-children-autism-show-difficulty-dueling-sensory-input



Thursday 24 April 2014

The Sensory Systems


SI is now better known as ASI or Ayers’ Sensory Integration that was founded by Dr. Jean Ayers,  an  occupational therapist and psychologist.  While working with children, she observed several behaviors that could not be adequately explained by neuromotor deficits alone. Her research revealed that sensory processing deficits interfered with development of appropriate behavior, language,  cognition, and social-emotional areas.

Let us understand the sensory systems as follows--
Tactile or touch: We first learn about an object through touch. Tactile input is associated with variable comfort to touch and the ability to discriminate different types of textures. This system also deals with oral skills.

Visual: the way we perceive form and space in 2 and 3 dimensional vision, depth perception, appreciate foreground v/s background, and visually discriminate in a given space.

Vestibular: deals with posture, muscle tone, eye movement, balance, attention, and gravitational security.

Proprioception: is the feeling we experience when we pull or push a heavy object. It is a system not well understood by most health professionals, but long emphasized by physiotherapists and occupational therapists. Proprioceptive sense provides us information about  position of our own body segments in relation to each other  and relation of the body to the environment.

Auditory:   our sense of hearing plays an important role in speech and language.

Olfactory :  our sense of smell.

Gustatory:  our  sense of taste that is closely related to the sense of taste. 

Interoception: our sense of how we feel what is going on in our body regarding sense of hunger, thirst, pain, need to use the washroom. 

It is critical to understand that all of these sensory systems work together so that we can learn and  function in life. Sensory systems are not watertight compartments where only a single system is working or impacted. 

According to Dr. Jean Ayers, sensory integration is the neurological process that organizes sensation from one’s own body and the environment, and makes it possible to use the body effectively to accomplish a meaningful task. This process means--

  •       Making sense of information from our own body and the world around us.
  •       Allowing us to function while using only the necessary input from within the body as well as the external environment.   
  • Processing only as much as required while filtering extraneous information.  
   
        
The function of the brain is to organize  information from all the sensory systems in order to produce a purposeful response. Input from all of the sensory systems is processed appropriately in the brain similar to performance of different musicians in a concert. The result is that a person can function at the given moment.
 Example 1—while attending a lecture in a room, your brain will filter out the honking sounds on the street or any uncomfortable situation within the room so that you can pay attention and take down notes. However the same sound of honking becomes a priority sensory  input when you cross a street. 
Example 2--driving in traffic with kids making sounds in the backseat of the car. Your brain will process the sensory  input only as needed so that your car does not hit another car in front of you and you can drive safely.
 Sensory integration occurs continuously  throughout the 24 hours. During sleeping hours we are able to respond to touch input by changing positions in the bed, or  walk in the dark to reach the bathroom. 

  Just as we need nutrition for the physical body, the central nervous system requires nutrition in the form of sensory input. The brain is not only reactive to information received through the sensory systems, but also proactively responds to anticipatory input. Example--you can avoid an obstacle on the street while walking and engaged in conversation with a friend, or move away to make space when a you see a person rushing towards you.


        Good sensory integrative abilities lead to body organization in space,  eye-hand coordination, speech and language skills, purposeful activity, and academic skills,


SI is intrinsic to human function.