Wednesday, March 23, 2011

Increasing the Intensity of Sensory Input

A sensory diet is when additional sensory input is added into the child's daily activities. This might include making sure the child runs around or swings at recess as opposed to them just sitting there on a bench. It might also include a child wearing a weighted vest or backpack while on an outing. The list is never ending of how sensory input can be weaved into a child's daily routines: marching between locations, vibrating pen, "heavy work" activities such as cleaning the chalkboard or carrying groceries for parents, or even extra trips to the neighborhood park.

So what is a parent to do when they have tried a sensory diet and the child still needs more? Well, that is when the occupational therapist (or other clinician trained in sensory integration techniques) analyzes the input the child is receiving. They should be asking about intensity, duration, frequency, and mode of sensation.

Intensity levels can be altered with jumping by adding a mini-trampoline versus just jumping on the ground. This can be made even more intense by the child jumping on a large outdoor trampoline. Another way intensity could be increased is to buy special suspended equipment such as swings with bungee cords that allow extra resistance as the child swings. These can be found at:

Some of the families I work with already have the outdoor play gyms that have a swing, slide, ladder, and "rock" wall. Often, suspended equipment could be used with these play gym systems. So a regular sling seat swing could be replaced with the "frog" swing which is also a sling seat, but has bungee rope at the top so the child is bouncing up-down in addition to being able to swing front-to-back.

Intensity could be added to marching by adding 1-2 pound leg weights around the child's ankles as he marches. Other ideas include: Joint compressions, a game of tug-of-war, deep massage vs. light touch, songs with words versus just instrments...and the list is never-ending!

Duration: length of time of sensory input. So, if the family tends to let the child play at the park for 20 minutes, maybe the time should be lengthened to 30 minutes or more. This is especially the case for a child who has sensory modulation disorder with the symptoms of sensory seeking or sensory under-responsiveness.

Frequency: means the amount of times during the day. If the child only gets one "wiggle" break at school/home then maybe the child needs more "wiggle" breaks. The average adult attention span is only 45 minutes of listening, and for children it is even less. So, we know that many special needs children can't focus as long as a typically developing, more "wiggle" breaks are needed! If breaks are not possible, then fidgets for the hands or a cushion for the bottom such as the Movin' Sit (R) could be helpful.

Mode of sensation: is the input tactile? auditory? visual? movement (vestibular and/or proprioceptive)? smell/taste? oral-motor? Changing up a sensory diet with various types of input may be necessary. This can be frustrating to teachers and parents because after a few months of the ideas given by the therapist they aren't getting as good of results. Altering the sensory diet can be a guessing game especially when the child fluctuates from day-to-day or even hour-to-hour!
Maybe if the child tends to like motion that is up-down such as bouncing on a ball or jumping on a trampoline, then a different kind of movement could be added to the sensory diet. Examples of more intense motion include rotary/spinning or upside down movement. Examples of less intense motion include front-to-back or side-to-side motion at a predictable pace.

I hope this article got you thinking! Once a sensory diet is in place, it probably will have to be tweaked here and there...especially if there are lots of changes in that child's life.

Saturday, March 12, 2011

Indwelling Thumbs in Children with Spasticity

It has been a BUSY month so far, so this is my first post of the month... the longest I've ever went without writing an entry! Oh well, Happy Spring (almost)!

Lately, I've been working with quite a few children of all ages who have spastic quadriplegia; this is when both legs and arms have extreme tightness due to neurological impairments, and typically the upper body is less functional than the lower body for these children. For the younger children such as infants and toddlers, I often suggest "Joe Cool" or "Benik" splints (sometimes with a harder material inserted between the thumb and index finger) in order to help the thumb not stay tucked in the hand. Some children require night-time splints (e.g. from orthoplast) as well, but I am simultaneously encouraging as much active movement as possible. But unfortunately, active movement isn't always possible; this is especially the case for a child who has suffered a near drowning, CMV, PLV, or a TBI. In that case if a splint isn't tolerated due to too much tightness and orthopedic mal-alignment of the fingers (wrists, IPs and MCPs), then I suggest rolling up a small washcloth within their hand. This gives the web-space a small amount of support without an excessive, painful stretch. If the thumb and fingers continue to be tight over numerous years, then the creases within the palm can become "stuck" to each other which makes it pretty much impossible to open the hand to full passive range of motion, and if it does occur the skin may rip and/or bleed. Even for the kids who may never actively move their hands due to severe physical and cognitive involvement, getting the thumb to not tuck is important... dislocated bones or "windswept" deformities can be painful!

Of course, I always promote massage, stretch, weight-bearing through an open hand, and active use of the muscles when possible. Also, some children need a customized splint created from an orthotist or occupational therapist. Some "ready made" dynamic splints may even work. In these cases, I have to investigate funding ideas if insurance doesn't reimburse for it and if the family doesn't have the financial means to pay for it.

I would love to hear other strategies for helping reduce indwelling thumbs in children with neurological damage. If you have any, send them my way!