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IMPROVING FUNCTION WITHA MULTI-SENSORY
APPROACH
Ann Brownstone, MS, OTR/L; SWCClinical Supervi soriLs Trainer
Sarah A. Schoen, Ph.D. OTRAssociate Direct or of ResearchSensory Processing Disorder Foundation
ANN BROWNSTONE, MS, OTR/ L; SWC
Clinical Supervisor, Associated Learning andLanguage Special ist s
Integrated Listening Systems Pract it ionerTrainer
SARAH A. SCHOEN, PH.D., OTR
Associat e Director of Research, SensoryProcessing Disorder Foundation
Clinical Services Advisor, Sensory Therapies
And Research (STAR) Center Assistant Professor, Rocky Mountain Universit y
of Healt h Professions
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OVERVIEW
OT and iLs: a Mult i-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 simult aneously:
Auditory
Vestibular
Visual
Proprioceptive/ Kinesthet ic wit h
additional challenges for Language(receptive & expressive)
Cognit ive skill s
THE THREE PROGRAMS OF ILS
AuditoryProgram
VisualBalanceCoordinationProgram
InteractiveLanguageProgram
Usedsimultaneouslyorindependently
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NEUROPLASTICITY
TheBrainChangesThroughoutLife!
Newneural
connections
are
created
through
stimulation
100billionneuronswiththousandsofconnections
Neuronsthatfiretogether,wiretogether
iLssoundandmovementprotocolsstrengthentheneuralcircuitryforsensoryprocessing:auditory,visual,balance
Frequency,intensity,durationRepetitionoftheiLsprotocolfacilitatesfunctionalintegration
HOW ILS WORKS
iLsisaMultiSensoryIntervention
Supportsandenhancessubcorticalprocessing(bottom
upprocessinginthebrainstemandcerebellum)
Subcorticalprocessingfacilitatesoptimalcognitiveprocessing
Whensubcorticalfunctionisweak,tutoringandothercognitivebasedmethodsdonotstick aswell
iLs keyingredientsforstrongfoundation:frequency,intensityandduration
AUDITORY PROGRAM
It all begins wit h frequencytransmission
AuditoryTransduction
Createdby&usedwithpermission
fromBrandonPletsch
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SOUND TRANSMISSION: BY AIR & BONE
Soundvibrationspassviathesmallbones (ossicles)ofthe
middleeartotheovalwindow.
THE ROLE OF THE MIDDLE EAR
Muscles of t he Middle Ear
Two muscles (t ensor t ympani and stapedius) r egulat ethree bones which transmit sound to the oval window
Most significant role is dampening volume to prot ect t he innerear
Small est muscles in the human body regulatingthesmallest bones
St riated (skeletal) muscles that can be st rengthened
VESTIBULAR SYSTEM INNER EAR
Thecochlea,semicircularcanalsandvestibule(utricleandsaccule)
containacontinuousfluid;thevestibuleandcochleaareonesystem.
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VESTIBULAR SYSTEM INNER EAR
Activated by gravity, movement and visual input(VOR)
Support s balance, posture, motor development,muscle tone, body concept , awareness of 3-D spaceand visual spatial skills
Processes input f rom all muscles (including extr a-ocular), j oint s, soles of feet and palms of hands
90%of the cortex receives input f rom the vest ibularorgans
Fully developed and functional at 14 weeks gestation
CEREBELLUM: THE PROCESSOR
Controls rhythm, t iming,processing speed, learningnovel skills and automaticity
90% of incoming input issensory
Only 10%leaves throughoutgoing pathways
Pathways to f rontal lobeinfluence cognition, emotion
AROUSAL: THE RAS
Ret icular Acti vat ing System (RAS)
Neural net i n the brain stem, wi th connect ions tothalamus
Receives dif fuse input fr om all sensory systems: gatesor facilitates attending
Prepares the brain t o receive and process specif icsensory input
Regulates levels of consciousness and wake/ sleeptransitions
Responsible for optimal stat e to be available tolearn
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AUTONOMIC NERVOUS SYSTEM
Sympathet ic System ( fight/ flight)
Many clients are stuck here Acti vated by fear or percepti on of t hreat
Parasympathet ic System (rest / digest) Produces calm, relaxation
Vagus Nerve major inf luence on this system
VAGUS NERVE
Carries 75%of all parasympathetic activity
Gates fight/ fl ight r esponse
St imulat ed by sound
Branches fr om external auditory canal
Branches fr om tympanic membrane
Controls heart rate, respirat ion, digest ion,homeostasis
AUDITORY PROCESSING
Audit ory Pathway is complex
Seven relay stati ons fr om the cochlea to the primaryauditory cortex of the brain
Errors in processing input at any one of t he relay
stat ions may compromise sound/ language processing
Superior Oli vary Nuclei f rom t his point, audit ory andvisual share pathways
Inferior Coll iculus
Superior Coll iculus
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KEY PRINCIPLES THAT INFORM ILS
The Ear is a Transducer
The ear (outer, middle, inner) transforms soundwaves into electrical signals.
Electr ical i mpulses are a battery t o t he brain.
KEY PRINCIPLES THAT INFORM ILS
Sound is a Nutr ient
High fr equencies are alert ing
Low fr equencies are grounding
Low f requencies help us connect wit h our body
Low frequencies, in excess , are fatiguing (e.g.,the drone of an airplane)
KEY PRINCIPLES THAT INFORM ILS
Listeni ng and Hearing
Listening is activeand involves social motivation
Hearing is the ability to perceive sound
We hear in two ways:
Air conduction
Bone conduction
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KEY PRINCIPLES THAT INFORM ILS
Three Zones*(identi fied by Dr. Tomat is)
Zone One: 0-750 Hz Sensory-Motor Zone
Zone Two: 750-3000 Hz Communicat ion Zone
Zone Three: 3000+ Hz Integrat ion Zone
* based on years of clinical testing
MUSIC CHOICES
Most ly Mozart universal appeal; form & structure of compositions; broad
dynamic range; rich in harmonics and overtones
Orchest ral Music diversity of instruments provide broad dynamic range
(symphonies, sonatas, serenades, etc. )
Other compositions chosen for their frequency content, rhythm and dynamic
range
Frequency Fil t rat ion Sample
FSM EHS FM 500 FM 1000 SM 0 - 2K SpL Chant
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BONE CONDUCTION DELIVERY
iLs delivers sound through both air and bone conduction
A key therapeutic mechanism of sound lies
in the natural f unction of the bones toconduct frequency
Sound is conducted through the bones of
the spine and skull t o the bony structure
around the inner ear
Lower frequencies conducted through bones Influence the
vestibul ar system, improving balance, coordinati on, mot orplanning, spatial awareness, emotional regulation
4PHASESOFILS PROGRAMS
4PHASESOFILS PROGRAMS
Each full-length program has 4 phases, in t his order:
OrganizationThe initial period of full spectrum music, and SMbandwidths
TransitionGradual removal of lower frequencies
ActivationThe highest filtered music level of the program
IntegrationThe gradual re-int roduct ion of the l ower frequenciesthat were removed during Transit ion Phase.
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ILS FOCUS PROGRAMSSensory Motor 60 hours
Balance, Coordinat ion, Muscle Tone, Spati al Awareness,Laterali ty as well as for those with significant delays in
reaching developmental landmarks and those on thespectrum
Concentration & Att ention 40 hours
Concentration, Attention, Ability toFocus, Memory, Moti vati on
Reading, Audit ory Processing 40 hours
Reading, Language, Speech, Art iculati on, Audit ory Processing
Optimal Performance 2 versions of 24 hours each
Concentration, Performance & Productivity, Energy, Mood,Enthusiasm
INTEGRATING VISUAL AND VESTIBULARINPUT
Playbook a guide for activit ies
Balance board
Adjustable tr acking ball
Racquetball
Bean bags
*optional use for i n-clinic OT practice;recommended for home
BREATHING, BALANCE & CORE
SAMPLE ACTIVITIES
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VISUAL MOTOR
SAMPLE ACTIVITIES
VISUAL TRACKING/ MOTOR PLANNING
SAMPLE ACTIVITIES
HEMISPHERIC INTEGRATION
SAMPLE ACTIVITIES
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OTHER ACTIVITIES WHILE LISTENING
Keep it f un
Quiet acti vit ies: puzzles and games
Creative activit ies: drawing, coloring, fi nger painting,molding clay
Start session wit h movement act ivi t ies
Adults oft en like yoga, st retching, r elaxing
INTERACTIVE LANGUAGE PROGRAM
(OPTIONAL)
Functional Language & Engagement, Reciproci ty
Loaded onto the iPod Touch
Children songsVocal production: i.e. humming, single & mult iple t ones
Repeating words, phrases, tongue twistersWords filt ered w/ high-pass fil ters (consonant practice)
w/ low-pass filt ers (vowel practice)Auditory memory
Auditory figure groundDichotic listening
INTERACTIVE LANGUAGE PROGRAM
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ILS DIFFERENCES Integrates an auditory program with vestibular, visual, and
functional language exercises
Delivers sound through both air and bone conduction: addedvesti bular stimulati on and calming eff ect
Individualized f or each child; combining cli nical reasoningwith easy-to-understand methodology
Gentle, gradual program design: begins gently and graduallyincreases information
Clinical & Equipment Support : available by phone or e-mail;advanced clinical support available with Ron Minson, MD
Professional Development: fr ee webinars; case study seriesand newslett ers monthly; repeat tr aining at discounted r ates
CASE STUDY
11 y/ o wit h Agenesis of t he Corpus Callosum,Congenit al Atrophic Cerebellum
Challenges: balance, contra-lateral movements, eyeteaming, apraxia, self-care dependent
Program: Zone 1 and 2 (body and cognit ivefunct ioning), 30 sessions over 12 weeks, no st ructuredexercises
Results: Improved balance (5 steps on balance beam),independently dressed himself aft er 15 sessions,improved handwrit ing, eye tr acking, oral motorarti culation, self expression
PILOT STUDY: COCHLEAR IMPLANTS
Cochlear implants, BAHAs, Hearing aides
Audiology, OT, SLP
Sound localizati on, f il tering background sound,decoding, sequencing, audit ory memory
Sensory Profi le, Peabody, VMI, cli nical observati ons,self-care report
March 2012 September 2012
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5420 S. Quebec St., Suit e 103
Greenwood Village, CO
303-221-STAR (7827)
www.starcenter.us
INTENSIVE MODEL
In town clients
3 to 5 t imes per week for 10 weeks
Out of town clients
5-10 times per weekfor 1-10 weeks
Break if possible
PROGRAM STRUCTURE
Intake
Evaluation: comprehensive OT or expanded multi-disciplinaryteam evaluation
Feedback: based on three priorities
Orientation: goal setting session (relationship building and GAScale)
~30 OT Treatment sessions; may also include DIR/ Floorti me,MD, LSW/ MFT, SLP (wit hin 30 sessions or added on)
Parents only educat ion ~ every 5th - 6th session
Break after ~ 60%of sessions (if indicated of 3 weeks to 3months)
Post-testing & recommendations
Boosters as needed
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TREATMENT BASED ON CLINICALREASONING
(Incl udes Many Frameworks And Models)
Integrated List ening Therapy
DIR/ Floorti meSOS Approach t o Feeding
Cognit ive Behavioral St rategies
Interactive Metronome
Kawar Ast ronaut Program
Wil barger Prot ocol
Wii
Kinect
And more
INTRODUCTION TO STAR CENTER
Differences from traditional OT model
1. Intensives, short term
2. Signif icant parent education
Famil y is also a focus of t reatment
Famil y part icipat ion in child s tr eatment session
Focus on teachi ng play to parents
3. Arousal modulat ion, relati onships & engagement,using sensory and motor acti vit ies
4. Clinical reasoning; process not acti vit y based
5. Sensory li festyl e (not a sensory diet )
INTRODUCTION TO STAR CENTER6. Turning over magic moments to parents
7. Focus on Joie de Vivre as well as physiologicsymptoms
8. Theme-based approach t o t reatment
9. Organizat ion of the session is done by child whenpossible (visual schedule)
10. Transit ions into and out of tr eatment are part ofintervention
11. Acti ve (vs. passive) use of sensation
12. Balance bet ween success and chall enge (so thatevery task is hard but scaffolded)
13. And iLs with many of our clients!
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STAR CENTER TREATMENT MODEL
& BEST PRACTICES
BEST PRACTICE USING THE STAR CENTERMODEL
Build Arousal Regulation for the Child & FamilyEngagement and Relat ionship is Pri marySensory integration and clinical reasoningTap the Child s Inner DriveParent educat ion and empowermentRe-enact the Problem AreaActive Participation to Control Arousal LevelChild - Selected Thematic PlayTherapist - Guides Session OrganizationIntensives - Parents Part icipation Fosters Model t hen Coach
Challenge must be j ust rightEnjoy YOUrself , Have Fun!!
SENSORY PROCESSING DISORDERTAXONOMY
SensoryModulation
Disorder (SMD)
SensoryBased Motor
Disorder(SBMD)
S OR S UR SC Dy sp rax ia P os tu ralDisorder
SensoryDiscrimination
Disorder (SDD)
SOR=SensoryOverResponsivity
SUR= SensoryUnderResponsivity
SC= SensoryCraving
Visual
Auditory
Tactile
Taste/Smell
Position/Mvmt
Interoception
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SENSORY MODULATION DISORDER
In Sensory Over-Responsivit y:
Emotionally Fearf ul, Anxious, or Angry
Behaviorally:
Hostile
Aggressive
Withdrawn
SENSORY MODULATION DISORDERCONT.
In Sensory Under-Responsivi t y
Emotionally Depressed
Behaviorally:
Flat Aff ect
Paucit y of Interactions
Hyperf ocused: can t shift att ention
SENSORY MODULATION DISORDERCONT.
In Sensory Craving
Emotionally errati c (fr om exuberant t o out ofcontrol)
Behaviorally:
In your face and in your space
On the go
Decreased att ention, distractibl e
Disorganized
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SENSORY-BASED MOTOR DISORDER
In Postural Disorder
Poor body scheme
Balance difficulties
Dif fi culty crossing the midl ine
Ocular problems
Weak muscle tone
Poor endurance
SENSORY-BASED MOTOR DISORDER
In Praxis
Arousal, Rhythmici ty and Sequencing
Ideation
Motor Organization
Planning (t houghts and actions)
Bilateral Coordinati on
Projected Action Sequences
Execut ion and Feedback
Problem Solvi ng and Organizat ion of Behavior
USE SENSORY MOTOR PROGRAM
Sensory Modulat ion Disorder
Sensory Over-Responsivi ty
Sensory Craving
May manipulate bone conduction to fit needs of child
Wit h SOR can turn down BC
With SUR can turn up t o +1 if tolerat ed
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WHAT HAVE WE LEARNED USING ILS?
Most childr en wit h SPD start wit h t he Sensory MotorProgram or t he Calming/ Prep Program
Be careful of overload when combiningvest ibular-based act ivi t ies and Bone Conduct ion
Some children may use supplemental program:Calming/ Preparatory wit h or wi thout chant
NUMBER OF SESSIONS PER WEEK
Younger childr en
3 sessions per week
Middle aged children
5 sessions per week
Older children
5 sessions 1-2 ti mes per day
Consistency is key!
PREPARATORY PROGRAM W/ OR W/ OCHANT
Use wit h
High anxiety
Sensory Over-Responsivi ty
Emotional dysregulation
Aut isti c Spectrum Disorder
Comprised of f ull spect rum music alt ernating wit hsensory motor
Signif icant bone conduct ion
Two versions: chant and musical
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CALMING PROGRAM
Useful wit h:
Children on the autism spectrum
Children wit h modulat ion disorders (SOR/ SC) Fullspectrum music for calming and relaxing
Can be preparatory pr ogram for
Children/ adolescents/ adult s
Wit h high stress or anxiety
TREATMENT BY SUBTYPE: SMD
Sensory Over-Responsive:
Only use Sensory Motor Program OR
Delay using iLs unti l aft er OT intensive OR
Begin wi th Calming Program
Use more humming and toning to decreasearousal
Especially i f emoti onall y reactive
SMD
Sensory Under-Responsive:
Extremely under-aroused children may needhigher f requencies sooner
St il l start wit h Sensory Motor program andobserve result
May benefit from actives early on
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SMD
Sensory Craving
Most of these children are over-aroused
Myth: r elat ed to SUR continuum
Start with Sensory Motor Program
SENSORY BASED MOTOR DISORDER
Postural Disorder
Simi lar to SUR, needs acti vation
Try using some higher bandwidths in betweenSensory Motor program and watch caref ull y for over-arousal
Try more bone conducti on if i t is tolerated (up to+1)
SBMD
Dyspraxia
Benefit fr om iLs during OT
Benefit from iLs as a follow-up after OT ispaused/ stopped
Especially if they have trouble organizing theirthoughts; or word r etri eval problems
With language delays same applies
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Sensory Discrimi nation Disorder :
iLs and OT during same ti me span but at separat etimes or on alternating days
Modify/ simpl if y your language signif icant ly if iLs andOT used together
SENSORYDISCRIMINATIONDISORDER
IN SENSORY DISCRIMINATION DISORDER E.G.,READING/ AUDITORY PROCESSING DIFFICULTIES
Use Reading/ Audit ory Processing Program
Intro period of full spectrum & sensory motor
Rapid t ransit ion phase
Focus is on
Zone 2 for language and communication
Zone 3 for reading comprehension and highercognit ive functi oning
WE HAVE OBSERVED
Low SI bandwidths are more calming and increaseregulation
Propriocept ive and heavy work compliments theSensory Motor Program
Use of bone conducti on helps postural cont rol improvemore quickly
e.g.,children with low tone who drool oftenincrease in tone in the oral region with lowbandwidths
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INTERACTIVE LANGUAGE PROGRAM
Pil ot data show an increase in physiological arousal when
children anticipate and start use of microphone withInt eract ive Language Program
Consider Int eract ive Language Program for SensoryUnder-responsive and Postural Disorder earl ier inprogram than you would for dysregulated children
CONCENTRATION/ ATTENTION PROGRAM
May be useful wit h the fol lowing diagnoses:
ADHD wit h co-morbid SPD (40%)
ADD wit h co-morbid SPD
Obsessive Compulsive features?(to assist wit h dividingattention)
ELECTRODERMAL ACTIVITYDURING A 50 MINUTE OT SESSION
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Ball
Pit
Swinging
Tunnel
Trampoline
LycraSwing
Wagon
Time(Hours:Minutes)
ElectrodermalActivity(microsiemens)
ChildsSkinConductanceduringTherapySession
EDR: 50-MINUTE OT SESSION IN WORDS
Speakinginto Mic
WIRELESS CONTINUOUS RECORDING OF EDA
Using wireless continuous recording of EDA, 77 usable treatment sessions weremonitored for arousal
Rosalind Picard Scd
MIT Media LaboratoryAffective Physiology
UNDERSTANDING AROUSAL CHANGES DURINGTREATMENT
Potent ial use during iLs:
Treatment studies need object ive markers
Wil l EDR be a useful marker of changes in the autonomicnervous system during and aft er intensive intervention?
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CURRENT AND PREVIOUS RESEARCH
73
HISTORICALLY, EFFECTS OF MUSIC
Listening to music can improve
Spatial t emporal reasoning
Mathemati cal abil it ies
Result s evident in cl ini cal groups ranging from
Healthy adults and children
St roke patients
Dyslexia
Insomniacs
EFFECTS OF MUSIC CONTINUED
Additi onal posit ive eff ects include
Decreased stress
Greater relaxation
Improved memory and attention
Bett er sleep patt erns
Improved phonological and spelling skills
Less fat igue
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ILS RESEARCH
Universit y of New Mexico
64 students (kindergarten 2nd grade)
Listening therapy plus art therapy
3 months of i ntervention
3 t imes a week
Average improvement i n reading ~ 2 years
EFFECTS OF PROCESSED MUSIC
Controversy exists
Mixed result s in t he lit erature
Lack of consistent fi ndings
Due to met hodological weaknesses
Programs not comparable
Samples not homogenous
Inappropriate met hods used
Few studies conducted using iLs
THERAPEEDS CLINIC
28 chil dren wit h auditory processing disorder
Age 7-14
Interventi on = OT combined wit h iLs
30-60 sessions
2-3 times a week
Changes noted in post rot ary nystagmus, ocular mot orskil ls, and audit ory processing
7 childr en wit h ADHD discont inued meds
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CONTINUED . . .
Auditory Brainstem Response
Binaural summation normalized following
intervention
measures the t ransmission of sound from the ears tothe low, middle and high port ions of t he brainstem.
This is an obj ecti ve measurement which tell s us ifthe ears are coordinating with each other.
DENVER ELEMENTARY SCHOOL
20 childr en, ages 5- 9 years
Diagnosis of learning disabilities
iLs Focus System 30 sessions, 3x per week i n school
Improvements included:
transitions from special education to regulareducation
having an IEP removed or
overcoming other emotional, behavioral oracademic defi cit s
ILS AND SPIRAL FOUNDATION
New studies: Effectiveness of iLs for children with Autism
Single Case Study
18 subjects
6 weeks of baseli ne, no t reatment
12 week int erventi on (5x per week) and playbookactivities
Outcome measures: standardi zed assessments andparent-report
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ILS AND SPD FOUNDATION
SPD Foundat ion r esearch proj ect on eff ecti veness of i Ls
Using mult ipl e case study methods we wil l t est
children, obtain baseline data, do an 8-week iLsprogram, 5 days a week (4 at home)
Measure 10 children pre-post (Physiological changese.g., elect rodermal activit y; Scan 3C, BASC II, ABASand Sensory Processing Scale
Measure each week EDA duri ng session (wirel esssensors) and Visual Analog scale of f ive goals parent shave for their child