IMPROVING FUNCTION WITH A MULTI-SENSORY APPROACH

Ann Brownstone, MS, OTR/L; SWC Clinical Supervisor iLs Trainer Sarah A. Schoen, Ph.D. OTR Associate Director of Research Sensory Processing Disorder Foundation

ANN BROWNSTONE, MS, OTR/L; SWC

Clinical Supervisor, Associated Learning and Language Specialists Integrated Listening Systems Practitioner Trainer

SARAH A. SCHOEN, PH.D., OTR

Associate Director of Research, Sensory Processing Disorder Foundation Clinical Services Advisor, Sensory Therapies And Research (STAR) Center Assistant Professor, Rocky Mountain University of Health Professions

OVERVIEW
OT and iLs: a Multi-Sensory Approach Neuroanatomy Key Components of iLs Clinical Applications Research Q and A

WHAT IS ILS?
A multi-sensory approach that provides input to the following sensory systems simultaneously: Auditory Vestibular Visual Proprioceptive/Kinesthetic with additional challenges for Language (receptive & expressive) Cognitive skills

THE THREE PROGRAMS OF ILS

AuditoryProgram

VisualBalanceCoordinationProgram

InteractiveLanguageProgram
Usedsimultaneouslyorindependently

NEUROPLASTICITY
TheBrainChangesThroughoutLife!
Newneuralconnectionsarecreatedthroughstimulation 100billionneuronswiththousandsofconnections Neuronsthatfiretogether,wiretogether iLssoundandmovementprotocolsstrengthentheneural circuitryforsensoryprocessing:auditory,visual,balance Frequency,intensity,duration RepetitionoftheiLsprotocolfacilitatesfunctionalintegration

HOW ILS WORKS

iLsisaMultiSensoryIntervention Supportsandenhancessubcorticalprocessing(bottom upprocessinginthebrainstemandcerebellum) Subcorticalprocessingfacilitatesoptimalcognitive processing Whensubcorticalfunctionisweak,tutoringand othercognitivebasedmethodsdonotstick aswell iLs keyingredientsforstrongfoundation:frequency, intensityandduration

AUDITORY PROGRAM
It all begins with frequency transmission
AuditoryTransduction
Createdby&usedwithpermission fromBrandonPletsch

SOUND TRANSMISSION: BY AIR & BONE

Soundvibrationspassviathesmallbones (ossicles)ofthe middleeartotheovalwindow.

THE ROLE OF THE MIDDLE EAR

Muscles of the Middle Ear
Two muscles (tensor tympani and stapedius) regulate three bones which transmit sound to the oval window
Most significant role is dampening volume to protect the inner ear

Smallest muscles in the human body regulating the smallest bones Striated (skeletal) muscles that can be strengthened

VESTIBULAR SYSTEM INNER EAR

Thecochlea,semicircularcanalsandvestibule(utricleandsaccule) containacontinuousfluid;thevestibuleandcochleaareonesystem.

VESTIBULAR SYSTEM INNER EAR

Activated by gravity, movement and visual input (VOR) Supports balance, posture, motor development, muscle tone, body concept, awareness of 3-D space and visual spatial skills Processes input from all muscles (including extraocular), joints, soles of feet and palms of hands 90% of the cortex receives input from the vestibular organs Fully developed and functional at 14 weeks gestation

CEREBELLUM: THE PROCESSOR

Controls rhythm, timing, processing speed, learning novel skills and automaticity 90% of incoming input is sensory Only 10% leaves through outgoing pathways
Pathways to frontal lobe influence cognition, emotion

AROUSAL: THE RAS

Reticular Activating System (RAS)
Neural net in the brain stem, with connections to thalamus Receives diffuse input from all sensory systems: gates or facilitates attending Prepares the brain to receive and process specific sensory input Regulates levels of consciousness and wake/sleep transitions Responsible for optimal state to be available to learn

AUTONOMIC NERVOUS SYSTEM

Sympathetic System (fight/flight)
Many clients are stuck here Activated by fear or perception of threat

Parasympathetic System (rest/digest)

Produces calm, relaxation Vagus Nerve major influence on this system

VAGUS NERVE
Carries 75% of all parasympathetic activity Gates fight/flight response Stimulated by sound Branches from external auditory canal Branches from tympanic membrane Controls heart rate, respiration, digestion, homeostasis

AUDITORY PROCESSING
Auditory Pathway is complex Seven relay stations from the cochlea to the primary auditory cortex of the brain Errors in processing input at any one of the relay stations may compromise sound/language processing Superior Olivary Nuclei from this point, auditory and visual share pathways Inferior Colliculus Superior Colliculus

KEY PRINCIPLES THAT INFORM ILS

The Ear is a Transducer The ear (outer, middle, inner) transforms sound waves into electrical signals. Electrical impulses are a battery to the brain.

KEY PRINCIPLES THAT INFORM ILS

Sound is a Nutrient High frequencies are alerting Low frequencies are grounding Low frequencies help us connect with our body Low frequencies, in excess , are fatiguing (e.g., the drone of an airplane)

KEY PRINCIPLES THAT INFORM ILS

Listening and Hearing Listening is active and involves social motivation Hearing is the ability to perceive sound We hear in two ways: Air conduction Bone conduction

KEY PRINCIPLES THAT INFORM ILS

Three Zones* (identified by Dr. Tomatis)

Zone One: 0-750 Hz Sensory-Motor Zone Zone Two: 750-3000 Hz Communication Zone Zone Three: 3000+ Hz Integration Zone

* based on years of clinical testing

MUSIC CHOICES
Mostly Mozart
universal appeal; form & structure of compositions; broad dynamic range; rich in harmonics and overtones diversity of instruments provide broad dynamic range (symphonies, sonatas, serenades, etc.) chosen for their frequency content, rhythm and dynamic range

Orchestral Music

Other compositions

Frequency Filtration Sample

FSM

EHS

FM 500

FM 1000

SM 0 - 2K

SpL

Chant

BONE CONDUCTION DELIVERY

iLs delivers sound through both air and bone conduction A key therapeutic mechanism of sound lies in the natural function of the bones to conduct frequency Sound is conducted through the bones of the spine and skull to the bony structure around the inner ear Lower frequencies conducted through bones Influence the vestibular system, improving balance, coordination, motor planning, spatial awareness, emotional regulation

4PHASESOFILS PROGRAMS

4PHASESOFILS PROGRAMS
Each full-length program has 4 phases, in this order: Organization The initial period of full spectrum music, and SM bandwidths Transition Gradual removal of lower frequencies Activation The highest filtered music level of the program Integration The gradual re-introduction of the lower frequencies that were removed during Transition Phase.

ILS FOCUS PROGRAMS

Sensory Motor 60 hours Balance, Coordination, Muscle Tone, Spatial Awareness, Laterality as well as for those with significant delays in reaching developmental landmarks and those on the spectrum Concentration & Attention 40 hours Concentration, Attention, Ability to Focus, Memory, Motivation Reading, Auditory Processing 40 hours Reading, Language, Speech, Articulation, Auditory Processing Optimal Performance 2 versions of 24 hours each Concentration, Performance & Productivity, Energy, Mood, Enthusiasm

INTEGRATING VISUAL AND VESTIBULAR INPUT

Playbook a guide for activities Balance board Adjustable tracking ball Racquetball Bean bags

*optional use for in-clinic OT practice; recommended for home

BREATHING, BALANCE & CORE

SAMPLE ACTIVITIES

VISUAL MOTOR

SAMPLE ACTIVITIES

VISUAL TRACKING/MOTOR PLANNING

SAMPLE ACTIVITIES

HEMISPHERIC INTEGRATION

SAMPLE ACTIVITIES

OTHER ACTIVITIES WHILE LISTENING

Keep it fun Quiet activities: puzzles and games Creative activities: drawing, coloring, finger painting, molding clay Start session with movement activities Adults often like yoga, stretching, relaxing

INTERACTIVE LANGUAGE PROGRAM

(OPTIONAL)

INTERACTIVE LANGUAGE PROGRAM

Functional Language & Engagement, Reciprocity Loaded onto the iPod Touch
Children songs Vocal production: i.e. humming, single & multiple tones Repeating words, phrases, tongue twisters Words filtered w/ high-pass filters (consonant practice) w/ low-pass filters (vowel practice) Auditory memory Auditory figure ground Dichotic listening

ILS DIFFERENCES
Integrates an auditory program with vestibular, visual, and functional language exercises Delivers sound through both air and bone conduction: added vestibular stimulation and calming effect Individualized for each child; combining clinical reasoning with easy-to-understand methodology Gentle, gradual program design: begins gently and gradually increases information Clinical & Equipment Support: available by phone or e-mail; advanced clinical support available with Ron Minson, MD Professional Development: free webinars; case study series and newsletters monthly; repeat training at discounted rates

CASE STUDY
11 y/o with Agenesis of the Corpus Callosum, Congenital Atrophic Cerebellum Challenges: balance, contra-lateral movements, eye teaming, apraxia, self-care dependent Program: Zone 1 and 2 (body and cognitive functioning), 30 sessions over 12 weeks, no structured exercises Results: Improved balance (5 steps on balance beam), independently dressed himself after 15 sessions, improved handwriting, eye tracking, oral motor articulation, self expression

PILOT STUDY: COCHLEAR IMPLANTS

Cochlear implants, BAHAs, Hearing aides Audiology, OT, SLP Sound localization, filtering background sound, decoding, sequencing, auditory memory Sensory Profile, Peabody, VMI, clinical observations, self-care report March 2012 September 2012

5420 S. Quebec St., Suite 103 Greenwood Village, CO 303-221-STAR (7827) www.starcenter.us

INTENSIVE MODEL
In town clients
3 to 5 times per week for 10 weeks

Out of town clients

5-10 times per week for 1-10 weeks Break if possible

PROGRAM STRUCTURE
Intake Evaluation: comprehensive OT or expanded multi-disciplinary team evaluation Feedback: based on three priorities Orientation: goal setting session (relationship building and GA Scale) ~30 OT Treatment sessions; may also include DIR/Floortime, MD, LSW/MFT, SLP (within 30 sessions or added on) Parents only education ~ every 5th - 6th session Break after ~ 60% of sessions (if indicated of 3 weeks to 3 months) Post-testing & recommendations Boosters as needed

(Includes Many Frameworks And Models) Integrated Listening Therapy DIR/Floortime SOS Approach to Feeding Cognitive Behavioral Strategies Interactive Metronome Kawar Astronaut Program Wilbarger Protocol Wii Kinect And more

TREATMENT BASED ON CLINICAL REASONING

INTRODUCTION TO STAR CENTER

Differences from traditional OT model 1. Intensives, short term 2. Significant parent education

Family is also a focus of treatment Family participation in childs treatment session Focus on teaching play to parents

3. Arousal modulation, relationships & engagement, using sensory and motor activities 4. Clinical reasoning; process not activity based 5. Sensory lifestyle (not a sensory diet)

INTRODUCTION TO STAR CENTER

6. Turning over magic moments to parents 7. Focus on Joie de Vivre as well as physiologic symptoms 8. Theme-based approach to treatment 9. Organization of the session is done by child when possible (visual schedule) 10. Transitions into and out of treatment are part of intervention 11. Active (vs. passive) use of sensation 12. Balance between success and challenge (so that every task is hard but scaffolded) 13. And iLs with many of our clients!

STAR CENTER TREATMENT MODEL & BEST PRACTICES

Build Arousal Regulation for the Child & Family Engagement and Relationship is Primary Sensory integration and clinical reasoning Tap the Childs Inner Drive Parent education and empowerment Re-enact the Problem Area Active Participation to Control Arousal Level Child - Selected Thematic Play Therapist - Guides Session Organization Intensives - Parents Participation Fosters Model then Coach Challenge must be just right Enjoy YOUrself, Have Fun!!

BEST PRACTICE USING THE STAR CENTER MODEL

SENSORY PROCESSING DISORDER TAXONOMY

SensoryModulation Disorder (SMD) SensoryBased Motor Disorder(SBMD) SensoryDiscrimination Disorder (SDD)

SOR

SUR

SC

Dyspraxia

PosturalDisorder

SOR=SensoryOverResponsivity SUR=SensoryUnderResponsivity SC=SensoryCraving

Visual Auditory Tactile Taste/Smell Position/Mvmt Interoception

SENSORY MODULATION DISORDER

In Sensory Over-Responsivity: Emotionally Fearful, Anxious, or Angry Behaviorally: Hostile Aggressive Withdrawn

SENSORY MODULATION DISORDER CONT.

In Sensory Under-Responsivity Emotionally Depressed Behaviorally: Flat Affect Paucity of Interactions Hyperfocused: cant shift attention

In Sensory Craving

SENSORY MODULATION DISORDER CONT.

Emotionally erratic (from exuberant to out of control) Behaviorally: In your face and in your space On the go Decreased attention, distractible Disorganized

SENSORY-BASED MOTOR DISORDER

In Postural Disorder Poor body scheme Balance difficulties Difficulty crossing the midline Ocular problems Weak muscle tone Poor endurance

SENSORY-BASED MOTOR DISORDER

In Praxis Arousal, Rhythmicity and Sequencing Ideation Motor Organization Planning (thoughts and actions) Bilateral Coordination Projected Action Sequences Execution and Feedback Problem Solving and Organization of Behavior

USE SENSORY MOTOR PROGRAM

Sensory Modulation Disorder Sensory Over-Responsivity Sensory Craving May manipulate bone conduction to fit needs of child With SOR can turn down BC With SUR can turn up to +1 if tolerated

WHAT HAVE WE LEARNED USING ILS?

Most children with SPD start with the Sensory Motor Program or the Calming/Prep Program Be careful of overload when combining vestibular-based activities and Bone Conduction Some children may use supplemental program: Calming/Preparatory with or without chant

NUMBER OF SESSIONS PER WEEK

Younger children 3 sessions per week

Middle aged children 5 sessions per week

Older children 5 sessions 1-2 times per day

Consistency is key!

Use with

PREPARATORY PROGRAM W/ OR W/O CHANT

High anxiety Sensory Over-Responsivity Emotional dysregulation Autistic Spectrum Disorder

Comprised of full spectrum music alternating with sensory motor Significant bone conduction Two versions: chant and musical

CALMING PROGRAM
Useful with: Children on the autism spectrum Children with modulation disorders (SOR/SC) Full spectrum music for calming and relaxing

Can be preparatory program for Children/adolescents/adults With high stress or anxiety

TREATMENT BY SUBTYPE: SMD

Sensory Over-Responsive:
Only use Sensory Motor Program OR Delay using iLs until after OT intensive OR Begin with Calming Program Use more humming and toning to decrease arousal Especially if emotionally reactive

SMD
Sensory Under-Responsive:
Extremely under-aroused children may need higher frequencies sooner Still start with Sensory Motor program and observe result May benefit from actives early on

SMD
Sensory Craving Most of these children are over-aroused Myth: related to SUR continuum Start with Sensory Motor Program

SENSORY BASED MOTOR DISORDER

Postural Disorder Similar to SUR, needs activation Try using some higher bandwidths in between Sensory Motor program and watch carefully for overarousal Try more bone conduction if it is tolerated (up to +1)

SBMD
Dyspraxia Benefit from iLs during OT Benefit from iLs as a follow-up after OT is paused/stopped Especially if they have trouble organizing their thoughts; or word retrieval problems With language delays same applies

SENSORYDISCRIMINATIONDISORDER
Sensory Discrimination Disorder: iLs and OT during same time span but at separate times or on alternating days Modify/simplify your language significantly if iLs and OT used together

IN SENSORY DISCRIMINATION DISORDER E.G.,

READING/AUDITORY PROCESSING DIFFICULTIES
Use Reading/Auditory Processing Program Intro period of full spectrum & sensory motor Rapid transition phase Focus is on Zone 2 for language and communication Zone 3 for reading comprehension and higher cognitive functioning

WE HAVE OBSERVED
Low SI bandwidths are more calming and increase regulation Proprioceptive and heavy work compliments the Sensory Motor Program Use of bone conduction helps postural control improve more quickly e.g.,children with low tone who drool often increase in tone in the oral region with low bandwidths

INTERACTIVE LANGUAGE PROGRAM

Pilot data show an increase in physiological arousal when children anticipate and start use of microphone with Interactive Language Program Consider Interactive Language Program for Sensory Under-responsive and Postural Disorder earlier in program than you would for dysregulated children

CONCENTRATION/ATTENTION PROGRAM
May be useful with the following diagnoses: ADHD with co-morbid SPD (40%) ADD with co-morbid SPD Obsessive Compulsive features? (to assist with dividing attention)

ELECTRODERMAL ACTIVITY
DURING A 50 MINUTE OT SESSION

EDR: 50-MINUTE OT SESSION IN WORDS

ChildsSkinConductanceduringTherapySession ElectrodermalActivity(microsiemens) BallPit LycraSwing Tunnel Swinging Speaking into Mic

Wagon Time(Hours:Minutes) Trampoline

WIRELESS CONTINUOUS RECORDING OF EDA

Using wireless continuous recording of EDA, 77 usable treatment sessions were monitored for arousal

Rosalind Picard Scd MIT Media Laboratory Affective Physiology

UNDERSTANDING AROUSAL CHANGES DURING TREATMENT

Potential use during iLs: Treatment studies need objective markers Will EDR be a useful marker of changes in the autonomic nervous system during and after intensive intervention?

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CURRENT AND PREVIOUS RESEARCH

HISTORICALLY, EFFECTS OF MUSIC

Listening to music can improve Spatial temporal reasoning Mathematical abilities Results evident in clinical groups ranging from Healthy adults and children Stroke patients Dyslexia Insomniacs

EFFECTS OF MUSIC CONTINUED

Additional positive effects include Decreased stress Greater relaxation Improved memory and attention Better sleep patterns Improved phonological and spelling skills Less fatigue

ILS RESEARCH
University of New Mexico 64 students (kindergarten 2nd grade) Listening therapy plus art therapy 3 months of intervention 3 times a week Average improvement in reading ~ 2 years

EFFECTS OF PROCESSED MUSIC

Controversy exists Mixed results in the literature Lack of consistent findings Due to methodological weaknesses Programs not comparable Samples not homogenous Inappropriate methods used Few studies conducted using iLs

THERAPEEDS CLINIC
28 children with auditory processing disorder Age 7-14 Intervention = OT combined with iLs 30-60 sessions 2-3 times a week Changes noted in post rotary nystagmus, ocular motor skills, and auditory processing 7 children with ADHD discontinued meds

CONTINUED . . .
Auditory Brainstem Response Binaural summation normalized following intervention measures the transmission of sound from the ears to the low, middle and high portions of the brainstem. This is an objective measurement which tells us if the ears are coordinating with each other.

DENVER ELEMENTARY SCHOOL

20 children, ages 5- 9 years Diagnosis of learning disabilities iLs Focus System 30 sessions, 3x per week in school Improvements included: transitions from special education to regular education having an IEP removed or overcoming other emotional, behavioral or academic deficits

ILS AND SPIRAL FOUNDATION

New studies: Effectiveness of iLs for children with Autism Single Case Study 18 subjects 6 weeks of baseline, no treatment 12 week intervention (5x per week) and playbook activities Outcome measures: standardized assessments and parent-report

ILS AND SPD FOUNDATION

SPD Foundation research project on effectiveness of iLs Using multiple case study methods we will test children, obtain baseline data, do an 8-week iLs program, 5 days a week (4 at home) Measure 10 children pre-post (Physiological changes e.g., electrodermal activity; Scan 3C, BASC II, ABAS and Sensory Processing Scale Measure each week EDA during session (wireless sensors) and Visual Analog scale of five goals parents have for their child