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== Introduction == | == Introduction == | ||
Sensory integration, or sensory processing, is the organisation of sensation for use.<ref name=":1" /> It refers to the ability of our brain to recognise and respond to signals sent by our sensory system. Our senses include hearing, vision, smell, taste, touch, proprioception | Sensory integration, or sensory processing, is the organisation of sensation for use.<ref name=":1" /> It refers to the ability of our brain to recognise and respond to signals sent by our sensory system. Our senses include hearing, vision, smell, taste, touch, proprioception, interoception, and our vestibular system - which provides information about movement, changing head position and gravity. | ||
Sensory integration plays an important role in a child's development | Sensory integration plays an important role in a child's development. This includes their ability to develop and maintain social-emotional relationships, as well as develop motor skills, cognitive skills, adaptive skills, and others.<ref name=":1">Chumburidze N. Sensory Integration. Plus Course 2024</ref> Children can be hypo- or hyper-sensitive to sensory inputs. When children have difficulty processing and responding to sensory information, their ability to participate in daily activities, school activities, etc. can be affected. | ||
Sensory integration (SI) has been described by Amy Stephens (director of Lifelong Learning) as a framework of reference to be used across the multidisciplinary team and as both an intervention and approach. The end point of SI, Amy further explains, is to allow the individual to identify what they need from their environment, and how they can manipulate their environment for what they need.<ref name=":10">Stephens A, Ruppel S. (G39) Transform Your Practice With Sensory Integration: A Free Course for Therapists - On Demand Webinar. Sensory Integration Education. Accessed May 01, 2024.https://www.sensoryintegrationeducation.com/courses/Transform-Your-Practice-with-Sensory-Integration</ref> | |||
'''This article provides a brief overview of sensory integration and offers recommendations for sensory integration therapy for children with cerebral palsy when sensory processing challenges are present.''' Optionally, read [[Sensory Integration Therapy in Paediatric Rehabilitation]] to learn more about the development, conditions treated, and the role of the Occupational Therapist. | |||
== Senses == | == Senses == | ||
== | While our five senses of touch, vision, hearing, smell and taste are commonly known, there are other senses which inform us about our bodies and the world they inhabit.<ref name=":8">Roley SS. [https://www.proedinc.com/Downloads/12565Ch01.pdf Sensory integration theory revisited. Sensory integration: applying clinical reasoning to practice with diverse populations]. Texas: Pro-Ed Inc. 2006:1-3.</ref> | ||
Both the five well-known senses as well as the other less known senses can be grouped into three areas namely:<ref name=":8" /> | |||
# '''Exteroception''' - Sensation from outside the body: Making use of the five common senses. | |||
# '''Proprioception''' - Sensation about body position and movement. | |||
# '''Interoception''' - Sensation from inside the body which is perceived through organs and viscera. | |||
Following is a brief description of the systems most commonly addressed and utilised in a therapeutic environment. | |||
=== Somatosensory system === | |||
* | The somatosensory system comprises of touch and proprioception.<ref name=":6" /> | ||
One of the most important functions of this system is [https://napacenter.org/praxis-occupational-therapy/#:~:text=Praxis%20is%20a%20multistep%20process,completion%20of%20an%20unfamiliar%20task. praxis]: being able to plan and execute tasks.<ref name=":6" /> | |||
==== 1. Touch / Tactile System ==== | |||
[[File:Cutaneous Receptors - Shutterstock - ID 283559897.jpg|thumb|Cutaneous Receptors]]The tactile system is the sense of touch. It is the sense which allows for the perception, organisation and integration of information through receptors on our skin.<ref>Hill J. What is the Tactile System [Internet]. 2021. [cited 07 May 2024]. Available from:[https://harkla.co/blogs/special-needs/tactile-system#:~:text=The%20tactile%20system%20is%20part,system%20to%20develop%20in%20utero. https://harkla.co/blogs/special-needs/tactile-system#:~:text=The%20tactile%20system%20is%20part,system%20to%20develop%20in%20utero.]</ref> | |||
Information is received from receptor cells in the skin: | |||
* '''Cutaneous''' receptors provide information about light touch, pressure, vibration, temperature, and pain | |||
* '''Mechanoreceptors''' detect touch:<ref>Marzvanyan A, Alhawaj AF. Physiology, Sensory Receptors. [Updated 2023 Aug 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539861/</ref><ref>Purves D, Augustine GJ, Fitzpatrick D, et al., editors. Neuroscience. 2nd edition. Sunderland (MA): Sinauer Associates; 2001. Mechanoreceptors Specialized to Receive Tactile Information. Available from: https://www.ncbi.nlm.nih.gov/books/NBK10895/</ref><ref>Iheanacho F, Vellipuram AR. Physiology, Mechanoreceptors. [Updated 2023 Sep 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541068/</ref> | * '''Mechanoreceptors''' detect touch:<ref>Marzvanyan A, Alhawaj AF. Physiology, Sensory Receptors. [Updated 2023 Aug 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539861/</ref><ref>Purves D, Augustine GJ, Fitzpatrick D, et al., editors. Neuroscience. 2nd edition. Sunderland (MA): Sinauer Associates; 2001. Mechanoreceptors Specialized to Receive Tactile Information. Available from: https://www.ncbi.nlm.nih.gov/books/NBK10895/</ref><ref>Iheanacho F, Vellipuram AR. Physiology, Mechanoreceptors. [Updated 2023 Sep 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541068/</ref> | ||
** Hair follicles: affect touch perception | ** Hair follicles: affect touch perception | ||
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** Ruffini corpuscles: detect stretch, as well as movement and finger position | ** Ruffini corpuscles: detect stretch, as well as movement and finger position | ||
** C-fibre low threshold mechanoreceptors (LTM) respond to “pleasant” and “effective” mechanical stimuli like gentle stroking and brushing and small changes in skin temperature<ref>Huzard D, Martin M, Maingret F, Chemin J, Jeanneteau F, Mery PF, Fossat P, Bourinet E, François A. [https://www.science.org/doi/epdf/10.1126/sciadv.abo7566 The impact of C-tactile low-threshold mechanoreceptors on affective touch and social interactions in mice.] Sci Adv. 2022 Jul;8(26):eabo7566.</ref> | ** C-fibre low threshold mechanoreceptors (LTM) respond to “pleasant” and “effective” mechanical stimuli like gentle stroking and brushing and small changes in skin temperature<ref>Huzard D, Martin M, Maingret F, Chemin J, Jeanneteau F, Mery PF, Fossat P, Bourinet E, François A. [https://www.science.org/doi/epdf/10.1126/sciadv.abo7566 The impact of C-tactile low-threshold mechanoreceptors on affective touch and social interactions in mice.] Sci Adv. 2022 Jul;8(26):eabo7566.</ref> | ||
* '''''Thermoreceptors''''' detect changes in temperature | * '''''Thermoreceptors''''' detect changes in temperature | ||
These receptors relay information to different areas of the brain, namely the primary sensory cortex and the secondary somatosensory cortex. | |||
Further somatosensory-vestibular-visual integration of information occurs in regions such as the vestibuli nuclei, thalamus and cortex.<ref name=":6" /> | |||
The tactile system has multiple functions which range from the simple reflex withdrawal, to complex integration with other senses.<ref name=":6" />Information received by the primary motor cortex is important for object manipulation and grasp, while information going to the secondary somatosensory region is involved in linking present and past sensations, needed in motor planning (a component of praxis). Tactile information is important in this process in regard to feedforward processing and prediction of movement .<ref name=":6" /> | |||
=== Proprioception === | ==== 2. Proprioception ==== | ||
[[Proprioception]] (kinaesthesia) helps us to move. Proprioception refers to information arising from skin, muscles, joints, ligaments, and bones.<ref name=":1" /> It allows us to perceive the location, movement, and actions of our body.<ref name=":2">Proske U, Gandevia SC. [https://journals.physiology.org/doi/epdf/10.1152/physrev.00048.2011 The proprioceptive senses: their roles in signalling body shape, body position and movement, and muscle force.] Physiol Rev. 2012 Oct;92(4):1651-97.</ref> | [[Proprioception]] (kinaesthesia) helps us to move. Proprioception refers to information arising from skin, muscles, joints, ligaments, and bones.<ref name=":1" /> It allows us to perceive the location, movement, and actions of our body.<ref name=":2">Proske U, Gandevia SC. [https://journals.physiology.org/doi/epdf/10.1152/physrev.00048.2011 The proprioceptive senses: their roles in signalling body shape, body position and movement, and muscle force.] Physiol Rev. 2012 Oct;92(4):1651-97.</ref>Moreover, the sense of effort, the sense of force and the sense of heaviness are all involved in proprioception.<ref>Proske U, Gandevia SC. [https://journals.physiology.org/doi/epdf/10.1152/physrev.00048.2011 The proprioceptive senses: their roles in signaling body shape, body position and movement, and muscle force.] Physiological reviews. 2012 Oct 1.</ref> | ||
* When we change position or move our limbs, the tissues (e.g. skin, muscle, tendons, etc) surrounding the moving joint are deformed<ref name=":2" /> | * When we change position or move our limbs, the tissues (e.g. skin, muscle, tendons, etc.) surrounding the moving joint are deformed<ref name=":2" /> | ||
* It has been su<nowiki/>ggested that [[Muscle Spindles|muscle spindles]] "play the major role in kinaesthesia"<ref name=":2" /> | * It has been su<nowiki/>ggested that [[Muscle Spindles|muscle spindles]] "play the major role in kinaesthesia"<ref name=":2" /> | ||
* The [[Skin Anatomy, Physiology, and Healing Process|skin receptors]] provide additional information<ref name=":2" /> | * The [[Skin Anatomy, Physiology, and Healing Process|skin receptors]] provide additional information<ref name=":2" /> | ||
* It is also suggested that [[Golgi Tendon Organ|Golgi tendon organs]] contribute to proprioception<ref name=":2" /> | * It is also suggested that [[Golgi Tendon Organ|Golgi tendon organs]] contribute to proprioception<ref name=":2" /> | ||
[[File:Proprioception - Shutterstock - ID 2407730613.jpg|thumb|380x380px|Proprioception|none]] | [[File:Proprioception - Shutterstock - ID 2407730613.jpg|thumb|380x380px|Proprioception|none]] | ||
=== Vestibular System === | === 3. Vestibular System === | ||
The vestibular system provides information about movement, gravity, and changing head position:<ref name=": | The vestibular system provides information about movement, gravity, and changing head position.<ref name=":1" /> It contains two receptor types:<ref name=":6">Lane SJ, Mailloux Z, Schoen S, Bundy A, May-Benson TA, Parham LD, Smith Roley S, Schaaf RC. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6680650/pdf/brainsci-09-00153.pdf Neural foundations of ayres sensory integration®]. Brain sciences. 2019 Jun 28;9(7):153.</ref> | ||
'''The semicircular canals''' - Detects angular movement of the head. | |||
'''The Otolith organs''' - Detects linear movement of the head and the pull of gravity. | |||
The vestibular system is linked to many regions and structures of the brain including the [[cerebellum]], [[Cranial Nerves|cranial nerves]] and even the cortex. This means that it plays a role in many functions of the brain and behaviors.<ref name=":6" /> | |||
One important function is arousal regulation. Rapid or unpredictable acceleration is associated with increased alertness, while slow, rhythmical movement is associated with calming and drowsiness.<ref name=":6" /> | |||
Neck and trunk musculature, important for head and postural control, is affected by vestibular input via the [[Vestibulospinal Tract|vestibulospinal]] tract. The refining of postural control is also affected by vestibular information coming to the cerebellum via the [[brainstem]]. Lane et al. (2019) highlighted the contribution the vestibular system has as a bilateral system, linking deficits in vestibular information to poor equilibrium reactions.<ref name=":6" /> | |||
Cranial nerves receiving vestibular information via the longitudinal fasciculus aids eye and head movements. This information provides stability to an individuals surroundings even when the person is moving.<ref name=":6" /> | |||
* | Connections to the visual and proprioceptive systems means that the vestibular information contributes towards anticipatory motor actions and plans.<ref name=":6" /> | ||
* | |||
In summary the vestibular system: | |||
* Affects arousal regulation | |||
* Affects postural control | |||
* Facilitates balance and equilibrium responses | |||
* Affects bilateral co-ordination | |||
* Aids in maintaining a stable visual field (helps to stabilise our eyes when we are moving) | |||
* Aids in spatial perception (telling us where we are in space and if the objects around us are moving or stationary) | |||
[[File:Vestibular System - Shutterstock - ID 2218792261.jpg|thumb|Vestibular System|none]]To learn more about the peripheral vestibular system, please click [[Introduction to Vestibular Rehabilitation#Anatomy of the Peripheral Vestibular System|here]]. | [[File:Vestibular System - Shutterstock - ID 2218792261.jpg|thumb|Vestibular System|none]]To learn more about the peripheral vestibular system, please click [[Introduction to Vestibular Rehabilitation#Anatomy of the Peripheral Vestibular System|here]]. | ||
=== Hearing / Auditory System === | === 4. Hearing / Auditory System === | ||
* The auditory system processes sound in the environment<ref name=":1" /> | * The auditory system processes sound in the environment<ref name=":1" /> | ||
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** for example, in situations where safety is a concern (e.g. a fire alarm goes off), we recognise the sound and act accordingly)<ref name=":1" /> | ** for example, in situations where safety is a concern (e.g. a fire alarm goes off), we recognise the sound and act accordingly)<ref name=":1" /> | ||
* Posture control can be influenced by sound frequency<ref>Siedlecka B, Sobera M, Sikora A, Drzewowska I. [https://www.actabio.pwr.wroc.pl/Vol17No3/11.pdf The influence of sounds on posture control]. Acta of Bioengineering and Biomechanics 2015;17(3):95-102.</ref> | * Posture control can be influenced by sound frequency<ref>Siedlecka B, Sobera M, Sikora A, Drzewowska I. [https://www.actabio.pwr.wroc.pl/Vol17No3/11.pdf The influence of sounds on posture control]. Acta of Bioengineering and Biomechanics 2015;17(3):95-102.</ref> | ||
=== Visual System === | === 5. Visual System === | ||
* Our visual system helps us see and perceive the environment around us<ref name=":1" /> | * Our visual system helps us see and perceive the environment around us<ref name=":1" /> | ||
* It identifies sights and understands what the eyes see<ref name=":1" /> | * It identifies sights and understands what the eyes see<ref name=":1" /> | ||
* Visual inspection is also important in maintaining body balance as it helps position the body in space<ref>Pankanin E. Visual control is important in maintaining the body's balance. Journal of Education, Health and Sport. 2018;8(8):381-387.</ref> | * Visual inspection is also important in maintaining body balance as it helps position the body in space<ref>Pankanin E. Visual control is important in maintaining the body's balance. Journal of Education, Health and Sport. 2018;8(8):381-387.</ref> | ||
[[File:Visual System - Shutterstock - ID 2393281423.jpg|thumb|200x200px|Visual System|none]] | [[File:Visual System - Shutterstock - ID 2393281423.jpg|thumb|200x200px|Visual System|none]] | ||
=== Smell / Olfactory System === | === 6. Smell / Olfactory System === | ||
* Our olfactory system allows us to distinguish various odours in the environment<ref name=":1" /> | * Our olfactory system allows us to distinguish various odours in the environment<ref name=":1" /> | ||
* | * The three olfactory functions include: | ||
[[File:Sense of Smell - Shutterstock - ID 2209889937.jpg|thumb|200x200px|Sense of Smell|none]] | ** Protection from environmental hazards - identifying safe or potentially dangerous situations (e.g. the smell of smoke)<ref name=":1" /><ref name=":7">Boesveldt S, Parma V. [https://link.springer.com/article/10.1007/s00441-020-03367-7 The importance of the olfactory system in human well-being, through nutrition and social behavior]. Cell and tissue research. 2021 Jan;383(1):559-67.</ref> | ||
=== Taste / Gustatory System === | ** Nutrition - Contributing to our appetite drive and food intake regulation. | ||
** Social behaviour - Human sweat, detected by our olfactory system is a powerful chemo-communicator and plays a role in fostering relationships. Smell is also involved in emotional regulation<ref name=":7" /> | |||
<blockquote>It is important to note that the olfactory system is closely linked to the limbic system, which is responsible for emotions, behaviours and memories.<ref name=":7" /></blockquote>[[File:Sense of Smell - Shutterstock - ID 2209889937.jpg|thumb|200x200px|Sense of Smell|none]] | |||
=== 7. Taste / Gustatory System === | |||
* Our gustatory system distinguishes four tastes: sweet, sour, salty, and bitter<ref name=":1" /> | * Our gustatory system distinguishes four tastes: sweet, sour, salty, and bitter<ref name=":1" /> | ||
* It is closely associated with the olfactory system | |||
* It allows us to identify desirable foods that are pleasant to us, as well as those that are potentially undesirable, such as a bitter dish<ref name=":1" /> | * It allows us to identify desirable foods that are pleasant to us, as well as those that are potentially undesirable, such as a bitter dish<ref name=":1" /> | ||
[[File: | [[File:Tongue and taste buds.jpg|thumb|Tongue and Taste Buds]] | ||
=== Interoception === | === 8. Interoception === | ||
Interoception is "the sense involved in the detection of internal regulation, such as heart rate, respiration, hunger, and digestion".<ref name=":0" /> Through interoception, we can distinguish our body's internal sensations.<ref>Sensory. Available from https://pathways.org/topics-of-development/sensory/ [last access 13.02.2024]</ref> | Interoception is "the sense involved in the detection of internal regulation, such as heart rate, respiration, hunger, and digestion".<ref name=":0">Camarata S, Miller LJ, Wallace MT. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7726187/pdf/fnint-14-556660.pdf Evaluating Sensory Integration/Sensory Processing Treatment: Issues and Analysis.] Front Integr Neurosci. 2020 Nov 26;14:556660.</ref> Through interoception, we can distinguish our body's internal sensations.<ref>Sensory. Available from https://pathways.org/topics-of-development/sensory/ [last access 13.02.2024]</ref> | ||
== Sensory Integration == | == Sensory Integration == | ||
<blockquote>Sensory integration "is the potential to develop adequate motor and behavioural reactions to stimulus." <ref>Ayres A. J. (1972). Sensory Integration and Learning Disorders. Los Angeles, CA: Western Psychological Services.</ref>-- Ayres</blockquote>The input from the senses is received, organised and interpreted to create a reaction appropriate to the stimuli received. This is called sensory processing. | <blockquote>Sensory integration or sensory processing "is the potential to develop adequate motor and behavioural reactions to stimulus."<ref>Ayres A. J. (1972). Sensory Integration and Learning Disorders. Los Angeles, CA: Western Psychological Services.</ref> -- Ayres</blockquote>The input from the senses is ''received'', ''organised'' and ''interpreted'' to create a reaction appropriate to the stimuli received. This is also called '''sensory processing'''.<ref name=":6" /> | ||
In 1960 Ayres proposed that:<ref name=":9">Smith Roley S, Mailloux Z, Miller-Kuhaneck H, Glennon TJ. [https://digitalcommons.sacredheart.edu/cgi/viewcontent.cgi?article=1017&context=ot_fac Understanding Ayres' sensory integration].</ref> | |||
# Learning takes place as a function of reward and reinforcement. | |||
# One learns what one does. | |||
# Learning takes place because there is a purpose for it's taking place. | |||
Ayres further proposed that '''development of the body scheme, development of posture and motor tasks, and even academic skills''' all needed the input of '''sensory information'''. In further regard, she emphasised how the sensory systems develop in relation to and because of one another.<ref name=":9" /> | |||
Sensory integration | Sensory integration theory places emphasis on "the active, dynamic sensory-motor processes that support movement as well as interaction within social and physical environments."<ref name=":6" /> | ||
* | A great guide to Sensory Integration and Sensory Process terms can be found in the [https://www.spdstar.org/sites/default/files/file-attachments/Sensory%20Integration%20%26%20Processing%20Jargon%20Guide%20-2020.pdf STAR Institute Sensory Integration & Processing Jargon Guide]. | ||
* | |||
* | == Sensory Integration / Processing Challenges == | ||
* | <blockquote>Sensory integration dysfunction is a problem in the ability to ‘‘organise sensory information for use.’’<ref>Ayres AJ. [https://autismodiario.org/wp-content/uploads/2011/05/The-1963-Eleanor-Clarke-Slagle-Lecture.pdf The development of perceptual-motor abilities: a theoretic basis for treatment of dysfunction]. Am J Occup Ther. 1963 Nov-Dec;17:221-5.</ref> -- Ayres</blockquote>Sensory function is essential for motor ability, social skills, and various behaviours. Adequate sensory integration allows for the foundation of adaptive behaviour. Disruption in '''modulation,''' '''discrimination''' or '''integration''' of sensory input can create a cascading effect that impacts all levels of sensory processing. This can include motor, social and behavioural components (impairments and activity level of the [[ICF-CY International Classification of Functioning, Disability and Health Children and Youth Version|ICF]] framework). This disruption can translate to problems with participation at home, school, and in the community.<ref name=":0" /><ref name=":6" /> | ||
* | |||
In general, sensory integration dysfunction may cause an individual to have difficulty with the following:<ref name=":0" /> | |||
* Initiating or sustaining peer interactions | |||
* Developing relationships | |||
* Participating in activities of daily living | |||
* Regulating arousal behaviours | |||
* Language development | |||
Sensory integration processing deficits may cause an individual to:<ref name=":0" /> | Sensory integration processing deficits may cause an individual to:<ref name=":0" /> | ||
* | * Respond to stimulation more quickly | ||
* | * Respond to stimulation more intensely | ||
* | * Respond to stimulation for longer than individuals who do not have difficulty with sensory integration processing | ||
Examples:<ref name=":0" /> | Examples:<ref name=":0" /> | ||
* | * Extreme responses to stimuli, including noise in a classroom, odours in a restaurant, the touch of clothing, or the movement of playground equipment. | ||
* "fight, flight or freeze" behavioural responses, such as aggression, withdrawal, or preoccupation with the expectation of sensory input | * The "fight, flight or freeze" behavioural responses, such as aggression, withdrawal, or preoccupation with the expectation of sensory input. | ||
* | * Severe difficulty forming and maintaining peer relationships. | ||
* | * Extreme efforts to control events in the environment by over-reliance on routines. | ||
* | *Behaviour regulation problems like temper tantrums, outbursts, hitting, kicking, biting, or spitting. | ||
* | *Profound withdrawal from the group. | ||
* | *Slow to respond to sensation, requiring "more intense stimuli to respond to the demands of the situation".<ref name=":0" /> | ||
=== Sensory Deficits and Cerebral Palsy === | === Sensory Deficits and Cerebral Palsy === | ||
Children with cerebral palsy often have deficits in one or more sensory systems, including proprioception, tactile sensation, and visual perception.<ref name=":1" /> This can affect their functional activities, especially bilateral arm activities, such as eating, playing, dressing, and showering.<ref>Erkek S, Çekmece Ç. [https://www.mdpi.com/2227-9067/10/11/1723 Investigation of the Relationship between Sensory-Processing Skills and Motor Functions in Children with Cerebral Palsy.] Children. 2023; 10(11):1723.</ref> A child with cerebral palsy and sensory processing difficulties might react to sensory stimuli in the following ways. | Children with cerebral palsy often have deficits in one or more sensory systems, including proprioception, tactile sensation, and visual perception.<ref name=":1" /> They can also have impairments in ''processing'' and ''modulating'' multisensory information which then affects their activity level, muscle tone, proprioception and emotional responses.<ref>Pavão SL, Rocha NA. [https://www.researchgate.net/profile/Silvia-Pavao/publication/269773831_Use_of_Sensory_Information_During_Postural_Control_in_Children_With_Cerebral_Palsy_Systematic_Review/links/5c081e734585157ac1aafa60/Use-of-Sensory-Information-During-Postural-Control-in-Children-With-Cerebral-Palsy-Systematic-Review.pdf Sensory processing disorders in children with cerebral palsy.] Infant Behavior and Development. 2017 Feb 1;46:1-6. </ref> | ||
This can affect their functional activities, especially bilateral arm activities, such as eating, playing, dressing, and showering.<ref>Erkek S, Çekmece Ç. [https://www.mdpi.com/2227-9067/10/11/1723 Investigation of the Relationship between Sensory-Processing Skills and Motor Functions in Children with Cerebral Palsy.] Children. 2023; 10(11):1723.</ref> A child with cerebral palsy and sensory processing difficulties might react to sensory stimuli in the following ways. | |||
* '''Hyper-responsiveness to tactile input''':<ref name=":1" /> | * '''Hyper-responsiveness to tactile input''':<ref name=":1" /> | ||
** | ** Does not like to be touched | ||
** | ** Avoids activities that involve getting messy | ||
** | ** Resists light touch | ||
** | ** Avoids certain types of clothing | ||
* '''Hypo-responsiveness to tactile input''':<ref name=":1" /> | * '''Hypo-responsiveness to tactile input''':<ref name=":1" /> | ||
** | ** Lacks the ability to localise touch or respond when touched | ||
** | ** Places items in their mouth | ||
** | ** May have a preference for activities or situations which involve brushing their hair, touching or hugging | ||
** | ** May fail to recognise when their hands or face are messy | ||
** | ** Enjoys activities involving vibration | ||
*'''Hyper-responsiveness to proprioceptive input:'''<ref name=":1" /> | *'''Hyper-responsiveness to proprioceptive input:'''<ref name=":1" /> | ||
** | ** Cries when they are in weight-bearing positions or when their joints are moved. | ||
** | ** Chooses not to move or engage in activities. | ||
* '''Hypo-responsiveness to proprioceptive input''':<ref name=":1" /> | * '''Hypo-responsiveness to proprioceptive input''':<ref name=":1" /> | ||
** | ** Bites or chews on non-food objects. | ||
** | ** Engages in pinching or hitting others or themself. | ||
** | ** Has difficulty changing body posture to match activity demands. | ||
** | ** May have low, high, or variable muscle tone, which impacts the processing of proprioceptive information. | ||
* '''Hyper-responsiveness to vestibular input:'''<ref name=":1" /> | * '''Hyper-responsiveness to vestibular input:'''<ref name=":1" /> | ||
** | ** Overreacts when moved in space. | ||
** | ** Becomes fearful of bouncing or swinging. | ||
** | ** Dislikes sudden or quick movements. | ||
* '''Hypo-responsiveness to vestibular input:'''<ref name=":1" /> | * '''Hypo-responsiveness to vestibular input:'''<ref name=":1" /> | ||
** | ** Enjoys being moved and rocked passively. | ||
** | ** Seeks opportunities to fall without regard to safety. | ||
** | ** Likes excessive spinning, swinging, and active movements. | ||
With children who are diagnosed with CP it is important to consider how they express or demonstrate their responsiveness to stimuli. A child may be able uses words to tell you when they like or don't like something, but a non-verbal child may communicate differently, especially when they are catagorised at a low [[Gross Motor Function Classification System - Expanded and Revised (GMFCS-ER)|GMFCS]] functioning level. A child may use sounds to communicate interest or level of alertness. Often a child who is overstimulated may become louder, but may also become quiet and inattentive as a form of 'shutdown'. | |||
Also look for indicators such as tone change - do they get stiffer when they engage in the input? Or do their movements change, e.g. in a child with dyskinesia they may have movements which increase in amplitude. Or a child may fix certain joints such as hips or knees or demonstrate greater 'posturing'. Other indicators include drooling (an increase in arousal in any system may increase this), or a change in visual attention within the activity. | |||
[[File:Level of arousal chart.jpg|center|thumb|600x600px]] | |||
== Sensory Integration Therapy == | == Sensory Integration Therapy == | ||
Sensory integration therapy (SIT) is done by trained occupational therapists, physiotherapists and even speech therapists, depending on the country and training required. | |||
The "hallmark" of SIT is that it is performed in the context of play, including activities which the children enjoy and that ensures that the activities are their own reward.<ref name=":9" /> | |||
SIT targets seven sensations: auditory, visual, gustatory (taste), olfactory (smell), somatosensory (proprioception and touch), vestibular, and interoception.<ref name=":0" /> It is suggested that SIT directly improves attentional, emotional, motor, communication, and/or social difficulties.<ref>Miller LJ, Fuller DA, Roetenberg J. Sensational Kids: Hope and Help for Children With Sensory Processing Disorder (SPD). New York, NY: Penguin, 2014.</ref>[[File:Pyramid-of-Learning (1).webp|none|thumb|600x600px|Pyramid of Learning]]The Pyramid of Learning is an illustration that depicts the foundational skills needed by a child and the skills which then 'build on top' of these. The base needs to be adequately addressed for successful development of the ascending tiers. This is know as the bottom-up approach.<ref>OT Plan. Pyramid of Learning. [Internet].[cited 14 May 2024]. Available from: https://otplan.com/pyramid-of-learning/</ref><blockquote>The goals of SIT is:<ref name=":1" /> | |||
# To facilitate a child's daily functioning. | |||
# To elicit a child's adaptive response in the form of an appropriate reaction to environmental or situational requirements. | |||
</blockquote> | |||
=== Key Principles of the Sensory Integrative Approach === | |||
'''The Just Right Challenge''' - Activities performed offer a challenge, but are always orientated for success.<ref name=":11">Schaaf RC, Miller LJ. [https://www.researchgate.net/profile/Roseann-Schaaf/publication/7767017_Occupational_therapy_using_a_sensory_integrative_approach_for_children_with_development_disabilities/links/5b97bf2392851c4ba80de045/Occupational-therapy-using-a-sensory-integrative-approach-for-children-with-development-disabilities.pdf Occupational therapy using a sensory integrative approach for children with developmental disabilities]. Mental retardation and developmental disabilities research reviews. 2005 Apr;11(2):143-8.</ref> | |||
'''The Adaptive Response''' - The individual or child will adapt their behaviour with new and useful strategies in response to the therapeutic challenge.<ref name=":11" /> | |||
'''Active Engagement''' - The individual/ child will actively participate in the environment and challenge developed by the therapist.<ref name=":11" /> | |||
''' | '''Child Directed''' - The therapist constantly observes behaviour and behavioural cues in the session. The cues provide leads to creating enticing and sensory-rich activities. The therapist follows the lead and suggestions of the individual/child.<ref name=":11" /> | ||
=== '''General recommendations''' === | |||
Some recommendations when applying SIT is:<ref name=":1" /> | |||
'''General recommendations | |||
* Establish clear goals | * Establish clear goals | ||
* Ensure the child's physical safety | * Ensure the child's physical safety | ||
* Prepare the child before starting an activity (safety, posture, muscle tone) | * Prepare the child before starting an activity (safety, posture, muscle tone) | ||
* Promote sensory-enriched activities | * Promote sensory-enriched activities when appropriate (reduce sensory input when needed) | ||
* Collaborate with the child on activity choice and maximise the child's success | * Collaborate with the child on activity choice and maximise the child's success | ||
* Guide self-organisation and support optimal arousal | * Guide self-organisation and support optimal arousal | ||
Line 150: | Line 228: | ||
* Determine the activity's intensity and duration | * Determine the activity's intensity and duration | ||
* Promote positive experiences and respect a child's preferences | * Promote positive experiences and respect a child's preferences | ||
* Integrate into daily routine | * Integrate into daily routine (like chores and art) | ||
* Incorporate every movement into play | * Incorporate every movement into play | ||
'''Other considerations related to Cerebral Palsy and SIT within an Occupational therapists perspective:<ref name=":4">Pollock N. [https://autismodiario.org/wp-content/uploads/2011/05/Sensory-Integration.pdf Sensory integration: A review of the current state of the evidence]. Occupational therapy now. 2009;11(5):6-10.</ref>''' | |||
=== | * The most important focus should be the occupations identified by the child and family. ''Note that occupation as defined in the therapeutic realm is anything which occupies one time in a meaningful way.'' | ||
* Consider multiple hypotheses in the occupational analysis for the sensory difficulty. | |||
* Make use of psychometrically sound outcome measures. | |||
* Set specific and measurable goals focused on the occupations and participation levels. | |||
* Involve the family and suggest changes to tasks and environment | |||
* Clearly explain the state of the evidence to the family, for an informed choice. | |||
=== The SI environment === | |||
Every '''environment''' a child resides in is appropriate for SIT, including schools, homes, yards, and playgrounds. However, sensory rooms tend to be utilised most frequently for treatment. Ensuring a child's physical safety is essential. Clinicians must carefully observe a child's reactions and pay attention to signs the child is becoming overwhelmed. If the child does become overwhelmed, the clinician should take prompt action and proactively change the situation.<ref name=":1" /> | Every '''environment''' a child resides in is appropriate for SIT, including schools, homes, yards, and playgrounds. However, sensory rooms tend to be utilised most frequently for treatment. Ensuring a child's physical safety is essential. Clinicians must carefully observe a child's reactions and pay attention to signs the child is becoming overwhelmed. If the child does become overwhelmed, the clinician should take prompt action and proactively change the situation.<ref name=":1" /> | ||
'''Equipment''' | '''Equipment''': A sensory room should include at least three inventories of working materials for each sensation:<ref name=":1" /> | ||
* tactile: sand, foam, various textures<ref name=":1" /> | * tactile: sand, foam, various textures<ref name=":1" /> | ||
Line 165: | Line 251: | ||
*smell: air fresheners (lavender, potpourri and sachets), candles, lotions, powders, perfumes, flowers, plants, breads, cookies, stews, bacon, onions<ref name=":3" /> | *smell: air fresheners (lavender, potpourri and sachets), candles, lotions, powders, perfumes, flowers, plants, breads, cookies, stews, bacon, onions<ref name=":3" /> | ||
*taste: fruits, milk-based items, hot and cold items, candies, cheese<ref name=":3" /> | *taste: fruits, milk-based items, hot and cold items, candies, cheese<ref name=":3" /> | ||
''Note: When introducing foods or liquids it is important to be aware of any allergies or food sensitivities. In addition, any loss of or impaired sensation must be screened for as well as a safe swallow. Children with CP often have sensory deficits or struggle with swallowing which makes them vulnerable to choking and aspiration, which could then lead to chest infections.'' | |||
=== Activities === | === Activities === | ||
The following activities are examples of how elements of | The following activities are examples of how elements of SI can be used to help treat sensory deficits depending on the sensory profile of the child. | ||
It is important to consider: | |||
a) What state the child is currently in, so as to determine which activities are required to bring the child into a regulated state. | |||
b) Which activities would be stimulating to a child's system, thus increasing arousal and which would be inhibitory and thus depressing to a child's system. | |||
==== Tactile Activities ==== | ==== 1. Tactile Activities ==== | ||
* Functional play with a sensory board and different tactile materials. | |||
* Playing with different brushes, drawing with soap crayons or chalk on the body, and erasing with various textures<ref name=":1" /> | * Playing with different brushes, drawing with soap crayons or chalk on the body, and erasing with various textures<ref name=":1" /> | ||
* Engaging in different play activities with Play-Doh, like hiding small objects in the Play-Doh or creating a tactile bin for finger exploration<ref name=":1" /> | * Engaging in different play activities with Play-Doh, like hiding small objects in the Play-Doh or creating a tactile bin for finger exploration<ref name=":1" /> | ||
* Exploring kitchen activities, such as mixing, tasting, smelling, and washing vegetables<ref name=":1" /> | * Exploring kitchen activities, such as mixing, tasting, smelling, and washing vegetables<ref name=":1" /> | ||
* Preparing a tactile bag (i.e. using a zipper bag filled with conditioner cream and food colours with small beans or toys hidden inside)<ref name=":1" /> | * Preparing a tactile bag (i.e. using a zipper bag filled with conditioner cream and food colours with small beans or toys hidden inside)<ref name=":1" /> | ||
* Creating sensory balloons (e.g. balloons filled up with materials like cereals, flowers, sand, etc)<ref name=":1" /> | * Creating sensory balloons (e.g. balloons filled up with materials like cereals, flowers, sand, etc.)<ref name=":1" /> | ||
* Making a tactile board using a piece of wood, tissue, and different materials<ref name=":1" /> | * Making a tactile board using a piece of wood, tissue, and different materials<ref name=":1" /> | ||
==== Proprioceptive Activities ==== | ==== 2. Proprioceptive Activities ==== | ||
* Engaging in playground activities<ref name=":1" /> | * Engaging in playground activities<ref name=":1" /> | ||
Line 186: | Line 280: | ||
* Resistance activities like pushing and pulling<ref name=":1" /> | * Resistance activities like pushing and pulling<ref name=":1" /> | ||
==== Vestibular Stimulation Activities ==== | ==== 3. Vestibular Stimulation Activities ==== | ||
* Spinning, rocking, climbing, sliding, riding toys, walking, running<ref name=":1" /> | * Spinning, rocking, climbing, sliding, riding toys, walking, running<ref name=":1" /> | ||
Line 195: | Line 289: | ||
* Swinging in a blanket, swing, or on a rope<ref name=":3" /> | * Swinging in a blanket, swing, or on a rope<ref name=":3" /> | ||
=== Safe-for-most strategies === | |||
The following strategies can be used for almost any sensory profile. They are used to regulate a child, in other words, bring them into the 'just-right' state for learning and engagement:<ref name=":10" /> | |||
# '''Linear vestibular''' - Slow back and forth movement. For example on a swing or hammock. | |||
# '''Deep pressure''' - A hug offered by another (co-regulation), swaddling in a blanket etc. | |||
# '''Low frequency vibration''' - Examples are a massage cushion or even driving in a car. For babies it can be seen as holding them close and letting them feel the vibration of your chest as you talk to them. This vibration generally spans between a sound you can hear and something you can feel in your body. It is of low pitch, not high buzzing. | |||
# '''Proprioception''' - Active movement of muscles. This is any movement against resistance or gravity. Often a favourite for children is crawling through a spandex tunnel (offering a resistance against limb movement). Active play incorporating whole body movement is another example. | |||
== To use SI or not to use SI == | |||
* Before incorporating Sensory Integration Therapy (SIT) into a rehabilitation plan, it is important to understand that there is a limited research evidence base for SIT, "with few positive outcomes and some null or negative outcomes" - when looking at the literature.<ref name=":0" /> | |||
* If the parents and therapists decide to use sensory integration therapy, they should establish clear, functional outcomes as the baseline before starting with therapy. This should be accompanied by parent, teacher and team member education. After 8-10 weeks the outcome measures should be completed again to determine if the intervention is effective.<ref name=":4" /> | |||
* A 2013 systematic review,<ref name=":5">Novak I, Mcintyre S, Morgan C, Campbell L, Dark L, Morton N, Stumbles E, Wilson SA, Goldsmith S. A [https://onlinelibrary.wiley.com/doi/pdf/10.1111/dmcn.12246 systematic review of interventions for children with cerebral palsy: state of the evidence.] Developmental medicine & child neurology. 2013 Oct;55(10):885-910.</ref> updated in 2020,<ref>Novak I, Morgan C, Fahey M, Finch-Edmondson M, Galea C, Hines A, et al. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7035308/ State of the evidence traffic lights 2019: systematic review of interventions for preventing and treating children with cerebral palsy]. Curr Neurol Neurosci Rep. 2020 Feb 21;20(2):3.</ref> concluded that sensory integration is a "red light therapy" with regards to cerebral palsy and is considered and ineffective treatment. Therapists are advised to have open discussions with the family regarding "green light therapy" which has been shown to be effective and evidence-based.<ref name=":5" /> | |||
* It is important to note that since 2013, more research studies have been conducted regarding the assessment of sensory deficits and sensory integration therapy with children with cerebral palsy, especially as an adjunct to other conventional therapy. | |||
** For instance a 2021 study showed that sensory integration therapy in combination with conventional physiotherapy exercises were more effective than just conventional therapy and exercises in improving gross motor function in children with cerebral palsy.<ref>Mahaseth PK, Choudhary A. [https://scholar.google.com/scholar_url?url=https://annalsofrscb.ro/index.php/journal/article/download/7608/5652&hl=en&sa=T&oi=gsb-gga&ct=res&cd=0&d=3569480099426794783&ei=IXAgZuLlIMzLy9YP792l4A4&scisig=AFWwaeZKJSKiF1tSCYhWX5vNwh47 Sensory integration therapy verses conventional physical therapy among children with cerebral palsy on gross motor function–a comparative randomized controlled trial]. Annals of the Romanian Society for Cell Biology. 2021 Apr 30:17315-34.</ref> | |||
=== Environment and Equipment === | |||
== Resources == | == Resources == | ||
*[https://www.sensoryintegrationeducation.com/pages/what-is-si What is Sensory Integration?] | *[https://www.sensoryintegrationeducation.com/pages/what-is-si What is Sensory Integration?] | ||
*Warutkar VB, Krishna Kovela R. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9695192/pdf/cureus-0014-00000030714.pdf Review of Sensory Integration Therapy for Children With Cerebral Palsy.] Cureus. 2022 Oct 26;14(10):e30714. | *Warutkar VB, Krishna Kovela R. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9695192/pdf/cureus-0014-00000030714.pdf Review of Sensory Integration Therapy for Children With Cerebral Palsy.] Cureus. 2022 Oct 26;14(10):e30714. | ||
*Case-Smith J, Weaver LL, Fristad MA. [https://capacity-resource.middletownautism.com/wp-content/uploads/sites/3/2015/07/CASE-SMITH-2014.pdf A systematic review of sensory processing interventions for children with autism spectrum disorders]. Autism. 2015 Feb;19(2):133-48. | |||
*Awalludin, ZA. [https://www.atlantis-press.com/proceedings/icalc-19/125937636 Sensory Integration and Functional Movement: A Guide to Optimal Development in Early Childhood]. 4th International Conference on Arts Language and Culture (ICALC 2019) | |||
*[https://pathways.org/tracking-sensory-development/ Tracking Sensory Development] | |||
== References == | == References == | ||
Revision as of 13:02, 13 May 2024
Original Editor - Based on a course by Nino Chumburidze
Top Contributors - Jess Bell, Ewa Jaraczewska, Lauren Heydenrych, Tarina van der Stockt and Nupur Smit Shah
This article or area is currently under construction and may only be partially complete. Please come back soon to see the finished work! (13/05/2024)
Introduction[edit | edit source]
Sensory integration, or sensory processing, is the organisation of sensation for use.[1] It refers to the ability of our brain to recognise and respond to signals sent by our sensory system. Our senses include hearing, vision, smell, taste, touch, proprioception, interoception, and our vestibular system - which provides information about movement, changing head position and gravity.
Sensory integration plays an important role in a child's development. This includes their ability to develop and maintain social-emotional relationships, as well as develop motor skills, cognitive skills, adaptive skills, and others.[1] Children can be hypo- or hyper-sensitive to sensory inputs. When children have difficulty processing and responding to sensory information, their ability to participate in daily activities, school activities, etc. can be affected.
Sensory integration (SI) has been described by Amy Stephens (director of Lifelong Learning) as a framework of reference to be used across the multidisciplinary team and as both an intervention and approach. The end point of SI, Amy further explains, is to allow the individual to identify what they need from their environment, and how they can manipulate their environment for what they need.[2]
This article provides a brief overview of sensory integration and offers recommendations for sensory integration therapy for children with cerebral palsy when sensory processing challenges are present. Optionally, read Sensory Integration Therapy in Paediatric Rehabilitation to learn more about the development, conditions treated, and the role of the Occupational Therapist.
Senses[edit | edit source]
While our five senses of touch, vision, hearing, smell and taste are commonly known, there are other senses which inform us about our bodies and the world they inhabit.[3]
Both the five well-known senses as well as the other less known senses can be grouped into three areas namely:[3]
- Exteroception - Sensation from outside the body: Making use of the five common senses.
- Proprioception - Sensation about body position and movement.
- Interoception - Sensation from inside the body which is perceived through organs and viscera.
Following is a brief description of the systems most commonly addressed and utilised in a therapeutic environment.
Somatosensory system[edit | edit source]
The somatosensory system comprises of touch and proprioception.[4]
One of the most important functions of this system is praxis: being able to plan and execute tasks.[4]
1. Touch / Tactile System[edit | edit source]
The tactile system is the sense of touch. It is the sense which allows for the perception, organisation and integration of information through receptors on our skin.[5]
Information is received from receptor cells in the skin:
- Cutaneous receptors provide information about light touch, pressure, vibration, temperature, and pain
- Mechanoreceptors detect touch:[6][7][8]
- Hair follicles: affect touch perception
- Pacinian corpuscles: sense vibrations and enable discrimination between smooth and rough surfaces / textures
- Meissner corpuscles: sensitive to light touch, including a light tickle - they detect vibration and fine, discriminative touch[9]
- Merkel complexes: detect skin indentation and provide information on texture, curvature, and shape[10] - they are activated by the applied pressure and location of objects we interact with
- Ruffini corpuscles: detect stretch, as well as movement and finger position
- C-fibre low threshold mechanoreceptors (LTM) respond to “pleasant” and “effective” mechanical stimuli like gentle stroking and brushing and small changes in skin temperature[11]
- Thermoreceptors detect changes in temperature
These receptors relay information to different areas of the brain, namely the primary sensory cortex and the secondary somatosensory cortex.
Further somatosensory-vestibular-visual integration of information occurs in regions such as the vestibuli nuclei, thalamus and cortex.[4]
The tactile system has multiple functions which range from the simple reflex withdrawal, to complex integration with other senses.[4]Information received by the primary motor cortex is important for object manipulation and grasp, while information going to the secondary somatosensory region is involved in linking present and past sensations, needed in motor planning (a component of praxis). Tactile information is important in this process in regard to feedforward processing and prediction of movement .[4]
2. Proprioception[edit | edit source]
Proprioception (kinaesthesia) helps us to move. Proprioception refers to information arising from skin, muscles, joints, ligaments, and bones.[1] It allows us to perceive the location, movement, and actions of our body.[12]Moreover, the sense of effort, the sense of force and the sense of heaviness are all involved in proprioception.[13]
- When we change position or move our limbs, the tissues (e.g. skin, muscle, tendons, etc.) surrounding the moving joint are deformed[12]
- It has been suggested that muscle spindles "play the major role in kinaesthesia"[12]
- The skin receptors provide additional information[12]
- It is also suggested that Golgi tendon organs contribute to proprioception[12]
3. Vestibular System[edit | edit source]
The vestibular system provides information about movement, gravity, and changing head position.[1] It contains two receptor types:[4]
The semicircular canals - Detects angular movement of the head.
The Otolith organs - Detects linear movement of the head and the pull of gravity.
The vestibular system is linked to many regions and structures of the brain including the cerebellum, cranial nerves and even the cortex. This means that it plays a role in many functions of the brain and behaviors.[4]
One important function is arousal regulation. Rapid or unpredictable acceleration is associated with increased alertness, while slow, rhythmical movement is associated with calming and drowsiness.[4]
Neck and trunk musculature, important for head and postural control, is affected by vestibular input via the vestibulospinal tract. The refining of postural control is also affected by vestibular information coming to the cerebellum via the brainstem. Lane et al. (2019) highlighted the contribution the vestibular system has as a bilateral system, linking deficits in vestibular information to poor equilibrium reactions.[4]
Cranial nerves receiving vestibular information via the longitudinal fasciculus aids eye and head movements. This information provides stability to an individuals surroundings even when the person is moving.[4]
Connections to the visual and proprioceptive systems means that the vestibular information contributes towards anticipatory motor actions and plans.[4]
In summary the vestibular system:
- Affects arousal regulation
- Affects postural control
- Facilitates balance and equilibrium responses
- Affects bilateral co-ordination
- Aids in maintaining a stable visual field (helps to stabilise our eyes when we are moving)
- Aids in spatial perception (telling us where we are in space and if the objects around us are moving or stationary)
To learn more about the peripheral vestibular system, please click here.
4. Hearing / Auditory System[edit | edit source]
- The auditory system processes sound in the environment[1]
- Auditory receptors in the inner ear identify various sound stimuli (e.g. loud / soft, far / near)[1]
- These sound stimuli are then processed by the central nervous system to determine an appropriate response
- for example, in situations where safety is a concern (e.g. a fire alarm goes off), we recognise the sound and act accordingly)[1]
- Posture control can be influenced by sound frequency[14]
5. Visual System[edit | edit source]
- Our visual system helps us see and perceive the environment around us[1]
- It identifies sights and understands what the eyes see[1]
- Visual inspection is also important in maintaining body balance as it helps position the body in space[15]
6. Smell / Olfactory System[edit | edit source]
- Our olfactory system allows us to distinguish various odours in the environment[1]
- The three olfactory functions include:
- Protection from environmental hazards - identifying safe or potentially dangerous situations (e.g. the smell of smoke)[1][16]
- Nutrition - Contributing to our appetite drive and food intake regulation.
- Social behaviour - Human sweat, detected by our olfactory system is a powerful chemo-communicator and plays a role in fostering relationships. Smell is also involved in emotional regulation[16]
It is important to note that the olfactory system is closely linked to the limbic system, which is responsible for emotions, behaviours and memories.[16]
7. Taste / Gustatory System[edit | edit source]
- Our gustatory system distinguishes four tastes: sweet, sour, salty, and bitter[1]
- It is closely associated with the olfactory system
- It allows us to identify desirable foods that are pleasant to us, as well as those that are potentially undesirable, such as a bitter dish[1]
8. Interoception[edit | edit source]
Interoception is "the sense involved in the detection of internal regulation, such as heart rate, respiration, hunger, and digestion".[17] Through interoception, we can distinguish our body's internal sensations.[18]
Sensory Integration[edit | edit source]
Sensory integration or sensory processing "is the potential to develop adequate motor and behavioural reactions to stimulus."[19] -- Ayres
The input from the senses is received, organised and interpreted to create a reaction appropriate to the stimuli received. This is also called sensory processing.[4]
In 1960 Ayres proposed that:[20]
- Learning takes place as a function of reward and reinforcement.
- One learns what one does.
- Learning takes place because there is a purpose for it's taking place.
Ayres further proposed that development of the body scheme, development of posture and motor tasks, and even academic skills all needed the input of sensory information. In further regard, she emphasised how the sensory systems develop in relation to and because of one another.[20]
Sensory integration theory places emphasis on "the active, dynamic sensory-motor processes that support movement as well as interaction within social and physical environments."[4]
A great guide to Sensory Integration and Sensory Process terms can be found in the STAR Institute Sensory Integration & Processing Jargon Guide.
Sensory Integration / Processing Challenges[edit | edit source]
Sensory integration dysfunction is a problem in the ability to ‘‘organise sensory information for use.’’[21] -- Ayres
Sensory function is essential for motor ability, social skills, and various behaviours. Adequate sensory integration allows for the foundation of adaptive behaviour. Disruption in modulation, discrimination or integration of sensory input can create a cascading effect that impacts all levels of sensory processing. This can include motor, social and behavioural components (impairments and activity level of the ICF framework). This disruption can translate to problems with participation at home, school, and in the community.[17][4]
In general, sensory integration dysfunction may cause an individual to have difficulty with the following:[17]
- Initiating or sustaining peer interactions
- Developing relationships
- Participating in activities of daily living
- Regulating arousal behaviours
- Language development
Sensory integration processing deficits may cause an individual to:[17]
- Respond to stimulation more quickly
- Respond to stimulation more intensely
- Respond to stimulation for longer than individuals who do not have difficulty with sensory integration processing
Examples:[17]
- Extreme responses to stimuli, including noise in a classroom, odours in a restaurant, the touch of clothing, or the movement of playground equipment.
- The "fight, flight or freeze" behavioural responses, such as aggression, withdrawal, or preoccupation with the expectation of sensory input.
- Severe difficulty forming and maintaining peer relationships.
- Extreme efforts to control events in the environment by over-reliance on routines.
- Behaviour regulation problems like temper tantrums, outbursts, hitting, kicking, biting, or spitting.
- Profound withdrawal from the group.
- Slow to respond to sensation, requiring "more intense stimuli to respond to the demands of the situation".[17]
Sensory Deficits and Cerebral Palsy[edit | edit source]
Children with cerebral palsy often have deficits in one or more sensory systems, including proprioception, tactile sensation, and visual perception.[1] They can also have impairments in processing and modulating multisensory information which then affects their activity level, muscle tone, proprioception and emotional responses.[22]
This can affect their functional activities, especially bilateral arm activities, such as eating, playing, dressing, and showering.[23] A child with cerebral palsy and sensory processing difficulties might react to sensory stimuli in the following ways.
- Hyper-responsiveness to tactile input:[1]
- Does not like to be touched
- Avoids activities that involve getting messy
- Resists light touch
- Avoids certain types of clothing
- Hypo-responsiveness to tactile input:[1]
- Lacks the ability to localise touch or respond when touched
- Places items in their mouth
- May have a preference for activities or situations which involve brushing their hair, touching or hugging
- May fail to recognise when their hands or face are messy
- Enjoys activities involving vibration
- Hyper-responsiveness to proprioceptive input:[1]
- Cries when they are in weight-bearing positions or when their joints are moved.
- Chooses not to move or engage in activities.
- Hypo-responsiveness to proprioceptive input:[1]
- Bites or chews on non-food objects.
- Engages in pinching or hitting others or themself.
- Has difficulty changing body posture to match activity demands.
- May have low, high, or variable muscle tone, which impacts the processing of proprioceptive information.
- Hyper-responsiveness to vestibular input:[1]
- Overreacts when moved in space.
- Becomes fearful of bouncing or swinging.
- Dislikes sudden or quick movements.
- Hypo-responsiveness to vestibular input:[1]
- Enjoys being moved and rocked passively.
- Seeks opportunities to fall without regard to safety.
- Likes excessive spinning, swinging, and active movements.
With children who are diagnosed with CP it is important to consider how they express or demonstrate their responsiveness to stimuli. A child may be able uses words to tell you when they like or don't like something, but a non-verbal child may communicate differently, especially when they are catagorised at a low GMFCS functioning level. A child may use sounds to communicate interest or level of alertness. Often a child who is overstimulated may become louder, but may also become quiet and inattentive as a form of 'shutdown'.
Also look for indicators such as tone change - do they get stiffer when they engage in the input? Or do their movements change, e.g. in a child with dyskinesia they may have movements which increase in amplitude. Or a child may fix certain joints such as hips or knees or demonstrate greater 'posturing'. Other indicators include drooling (an increase in arousal in any system may increase this), or a change in visual attention within the activity.
Sensory Integration Therapy[edit | edit source]
Sensory integration therapy (SIT) is done by trained occupational therapists, physiotherapists and even speech therapists, depending on the country and training required.
The "hallmark" of SIT is that it is performed in the context of play, including activities which the children enjoy and that ensures that the activities are their own reward.[20]
SIT targets seven sensations: auditory, visual, gustatory (taste), olfactory (smell), somatosensory (proprioception and touch), vestibular, and interoception.[17] It is suggested that SIT directly improves attentional, emotional, motor, communication, and/or social difficulties.[24]
The Pyramid of Learning is an illustration that depicts the foundational skills needed by a child and the skills which then 'build on top' of these. The base needs to be adequately addressed for successful development of the ascending tiers. This is know as the bottom-up approach.[25]
The goals of SIT is:[1]
- To facilitate a child's daily functioning.
- To elicit a child's adaptive response in the form of an appropriate reaction to environmental or situational requirements.
Key Principles of the Sensory Integrative Approach[edit | edit source]
The Just Right Challenge - Activities performed offer a challenge, but are always orientated for success.[26]
The Adaptive Response - The individual or child will adapt their behaviour with new and useful strategies in response to the therapeutic challenge.[26]
Active Engagement - The individual/ child will actively participate in the environment and challenge developed by the therapist.[26]
Child Directed - The therapist constantly observes behaviour and behavioural cues in the session. The cues provide leads to creating enticing and sensory-rich activities. The therapist follows the lead and suggestions of the individual/child.[26]
General recommendations[edit | edit source]
Some recommendations when applying SIT is:[1]
- Establish clear goals
- Ensure the child's physical safety
- Prepare the child before starting an activity (safety, posture, muscle tone)
- Promote sensory-enriched activities when appropriate (reduce sensory input when needed)
- Collaborate with the child on activity choice and maximise the child's success
- Guide self-organisation and support optimal arousal
- Build a therapeutic alliance through positive and supportive relationships
- Provide a "just-right" challenge
- Determine the activity's intensity and duration
- Promote positive experiences and respect a child's preferences
- Integrate into daily routine (like chores and art)
- Incorporate every movement into play
Other considerations related to Cerebral Palsy and SIT within an Occupational therapists perspective:[27]
- The most important focus should be the occupations identified by the child and family. Note that occupation as defined in the therapeutic realm is anything which occupies one time in a meaningful way.
- Consider multiple hypotheses in the occupational analysis for the sensory difficulty.
- Make use of psychometrically sound outcome measures.
- Set specific and measurable goals focused on the occupations and participation levels.
- Involve the family and suggest changes to tasks and environment
- Clearly explain the state of the evidence to the family, for an informed choice.
The SI environment[edit | edit source]
Every environment a child resides in is appropriate for SIT, including schools, homes, yards, and playgrounds. However, sensory rooms tend to be utilised most frequently for treatment. Ensuring a child's physical safety is essential. Clinicians must carefully observe a child's reactions and pay attention to signs the child is becoming overwhelmed. If the child does become overwhelmed, the clinician should take prompt action and proactively change the situation.[1]
Equipment: A sensory room should include at least three inventories of working materials for each sensation:[1]
- tactile: sand, foam, various textures[1]
- proprioception: ball pool / pit, therapy ball, heavy blanket[1]
- vestibular: platform swing, bolster swing, net swing, tilt board, trampoline, ramp[28]
- hearing: water (fountains, faucets, waves, and waterfalls), music (radio, instruments, chimes), instruments (drums, piano, guitar, keyboards and tambourines)[29]
- visual: neon, patterned and florescent papers, coloured, strung, flashing, holiday and strobe lights, wind socks, wind-up toys, activity boxes and age-appropriate mobiles[29]
- smell: air fresheners (lavender, potpourri and sachets), candles, lotions, powders, perfumes, flowers, plants, breads, cookies, stews, bacon, onions[29]
- taste: fruits, milk-based items, hot and cold items, candies, cheese[29]
Note: When introducing foods or liquids it is important to be aware of any allergies or food sensitivities. In addition, any loss of or impaired sensation must be screened for as well as a safe swallow. Children with CP often have sensory deficits or struggle with swallowing which makes them vulnerable to choking and aspiration, which could then lead to chest infections.
Activities[edit | edit source]
The following activities are examples of how elements of SI can be used to help treat sensory deficits depending on the sensory profile of the child.
It is important to consider:
a) What state the child is currently in, so as to determine which activities are required to bring the child into a regulated state.
b) Which activities would be stimulating to a child's system, thus increasing arousal and which would be inhibitory and thus depressing to a child's system.
1. Tactile Activities[edit | edit source]
- Functional play with a sensory board and different tactile materials.
- Playing with different brushes, drawing with soap crayons or chalk on the body, and erasing with various textures[1]
- Engaging in different play activities with Play-Doh, like hiding small objects in the Play-Doh or creating a tactile bin for finger exploration[1]
- Exploring kitchen activities, such as mixing, tasting, smelling, and washing vegetables[1]
- Preparing a tactile bag (i.e. using a zipper bag filled with conditioner cream and food colours with small beans or toys hidden inside)[1]
- Creating sensory balloons (e.g. balloons filled up with materials like cereals, flowers, sand, etc.)[1]
- Making a tactile board using a piece of wood, tissue, and different materials[1]
2. Proprioceptive Activities[edit | edit source]
- Engaging in playground activities[1]
- Participating in gross motor activities[1]
- Encouraging imitations of various movements[1]
- Weight-bearing activities, such as crawling and push-ups[1]
- Resistance activities like pushing and pulling[1]
3. Vestibular Stimulation Activities[edit | edit source]
- Spinning, rocking, climbing, sliding, riding toys, walking, running[1]
- Standing on one foot, progressing to standing on one foot with eyes closed[29]
- Throwing a ball[29]
- Shaking head or turning head from left to right at a rapid pace[29]
- Bouncing on a bed, ball or parent’s knees[29]
- Swinging in a blanket, swing, or on a rope[29]
Safe-for-most strategies[edit | edit source]
The following strategies can be used for almost any sensory profile. They are used to regulate a child, in other words, bring them into the 'just-right' state for learning and engagement:[2]
- Linear vestibular - Slow back and forth movement. For example on a swing or hammock.
- Deep pressure - A hug offered by another (co-regulation), swaddling in a blanket etc.
- Low frequency vibration - Examples are a massage cushion or even driving in a car. For babies it can be seen as holding them close and letting them feel the vibration of your chest as you talk to them. This vibration generally spans between a sound you can hear and something you can feel in your body. It is of low pitch, not high buzzing.
- Proprioception - Active movement of muscles. This is any movement against resistance or gravity. Often a favourite for children is crawling through a spandex tunnel (offering a resistance against limb movement). Active play incorporating whole body movement is another example.
To use SI or not to use SI[edit | edit source]
- Before incorporating Sensory Integration Therapy (SIT) into a rehabilitation plan, it is important to understand that there is a limited research evidence base for SIT, "with few positive outcomes and some null or negative outcomes" - when looking at the literature.[17]
- If the parents and therapists decide to use sensory integration therapy, they should establish clear, functional outcomes as the baseline before starting with therapy. This should be accompanied by parent, teacher and team member education. After 8-10 weeks the outcome measures should be completed again to determine if the intervention is effective.[27]
- A 2013 systematic review,[30] updated in 2020,[31] concluded that sensory integration is a "red light therapy" with regards to cerebral palsy and is considered and ineffective treatment. Therapists are advised to have open discussions with the family regarding "green light therapy" which has been shown to be effective and evidence-based.[30]
- It is important to note that since 2013, more research studies have been conducted regarding the assessment of sensory deficits and sensory integration therapy with children with cerebral palsy, especially as an adjunct to other conventional therapy.
- For instance a 2021 study showed that sensory integration therapy in combination with conventional physiotherapy exercises were more effective than just conventional therapy and exercises in improving gross motor function in children with cerebral palsy.[32]
Environment and Equipment[edit | edit source]
Resources[edit | edit source]
- What is Sensory Integration?
- Warutkar VB, Krishna Kovela R. Review of Sensory Integration Therapy for Children With Cerebral Palsy. Cureus. 2022 Oct 26;14(10):e30714.
- Case-Smith J, Weaver LL, Fristad MA. A systematic review of sensory processing interventions for children with autism spectrum disorders. Autism. 2015 Feb;19(2):133-48.
- Awalludin, ZA. Sensory Integration and Functional Movement: A Guide to Optimal Development in Early Childhood. 4th International Conference on Arts Language and Culture (ICALC 2019)
- Tracking Sensory Development
References[edit | edit source]
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.25 1.26 1.27 1.28 1.29 1.30 1.31 1.32 1.33 1.34 1.35 1.36 1.37 Chumburidze N. Sensory Integration. Plus Course 2024
- ↑ 2.0 2.1 Stephens A, Ruppel S. (G39) Transform Your Practice With Sensory Integration: A Free Course for Therapists - On Demand Webinar. Sensory Integration Education. Accessed May 01, 2024.https://www.sensoryintegrationeducation.com/courses/Transform-Your-Practice-with-Sensory-Integration
- ↑ 3.0 3.1 Roley SS. Sensory integration theory revisited. Sensory integration: applying clinical reasoning to practice with diverse populations. Texas: Pro-Ed Inc. 2006:1-3.
- ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 Lane SJ, Mailloux Z, Schoen S, Bundy A, May-Benson TA, Parham LD, Smith Roley S, Schaaf RC. Neural foundations of ayres sensory integration®. Brain sciences. 2019 Jun 28;9(7):153.
- ↑ Hill J. What is the Tactile System [Internet]. 2021. [cited 07 May 2024]. Available from:https://harkla.co/blogs/special-needs/tactile-system#:~:text=The%20tactile%20system%20is%20part,system%20to%20develop%20in%20utero.
- ↑ Marzvanyan A, Alhawaj AF. Physiology, Sensory Receptors. [Updated 2023 Aug 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539861/
- ↑ Purves D, Augustine GJ, Fitzpatrick D, et al., editors. Neuroscience. 2nd edition. Sunderland (MA): Sinauer Associates; 2001. Mechanoreceptors Specialized to Receive Tactile Information. Available from: https://www.ncbi.nlm.nih.gov/books/NBK10895/
- ↑ Iheanacho F, Vellipuram AR. Physiology, Mechanoreceptors. [Updated 2023 Sep 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541068/
- ↑ Piccinin MA, Miao JH, Schwartz J. Histology, Meissner Corpuscle. [Updated 2023 Mar 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK518980/
- ↑ Bataille-Savattier A, Le Gall-Ianotto C, Lebonvallet N, Misery L, Talagas M. Do Merkel complexes initiate mechanical itch? Exp Dermatol. 2023 Feb;32(2):226-234.
- ↑ Huzard D, Martin M, Maingret F, Chemin J, Jeanneteau F, Mery PF, Fossat P, Bourinet E, François A. The impact of C-tactile low-threshold mechanoreceptors on affective touch and social interactions in mice. Sci Adv. 2022 Jul;8(26):eabo7566.
- ↑ 12.0 12.1 12.2 12.3 12.4 Proske U, Gandevia SC. The proprioceptive senses: their roles in signalling body shape, body position and movement, and muscle force. Physiol Rev. 2012 Oct;92(4):1651-97.
- ↑ Proske U, Gandevia SC. The proprioceptive senses: their roles in signaling body shape, body position and movement, and muscle force. Physiological reviews. 2012 Oct 1.
- ↑ Siedlecka B, Sobera M, Sikora A, Drzewowska I. The influence of sounds on posture control. Acta of Bioengineering and Biomechanics 2015;17(3):95-102.
- ↑ Pankanin E. Visual control is important in maintaining the body's balance. Journal of Education, Health and Sport. 2018;8(8):381-387.
- ↑ 16.0 16.1 16.2 Boesveldt S, Parma V. The importance of the olfactory system in human well-being, through nutrition and social behavior. Cell and tissue research. 2021 Jan;383(1):559-67.
- ↑ 17.0 17.1 17.2 17.3 17.4 17.5 17.6 17.7 Camarata S, Miller LJ, Wallace MT. Evaluating Sensory Integration/Sensory Processing Treatment: Issues and Analysis. Front Integr Neurosci. 2020 Nov 26;14:556660.
- ↑ Sensory. Available from https://pathways.org/topics-of-development/sensory/ [last access 13.02.2024]
- ↑ Ayres A. J. (1972). Sensory Integration and Learning Disorders. Los Angeles, CA: Western Psychological Services.
- ↑ 20.0 20.1 20.2 Smith Roley S, Mailloux Z, Miller-Kuhaneck H, Glennon TJ. Understanding Ayres' sensory integration.
- ↑ Ayres AJ. The development of perceptual-motor abilities: a theoretic basis for treatment of dysfunction. Am J Occup Ther. 1963 Nov-Dec;17:221-5.
- ↑ Pavão SL, Rocha NA. Sensory processing disorders in children with cerebral palsy. Infant Behavior and Development. 2017 Feb 1;46:1-6.
- ↑ Erkek S, Çekmece Ç. Investigation of the Relationship between Sensory-Processing Skills and Motor Functions in Children with Cerebral Palsy. Children. 2023; 10(11):1723.
- ↑ Miller LJ, Fuller DA, Roetenberg J. Sensational Kids: Hope and Help for Children With Sensory Processing Disorder (SPD). New York, NY: Penguin, 2014.
- ↑ OT Plan. Pyramid of Learning. [Internet].[cited 14 May 2024]. Available from: https://otplan.com/pyramid-of-learning/
- ↑ 26.0 26.1 26.2 26.3 Schaaf RC, Miller LJ. Occupational therapy using a sensory integrative approach for children with developmental disabilities. Mental retardation and developmental disabilities research reviews. 2005 Apr;11(2):143-8.
- ↑ 27.0 27.1 Pollock N. Sensory integration: A review of the current state of the evidence. Occupational therapy now. 2009;11(5):6-10.
- ↑ Rassafiani M, Akbarfaimi N, Hosseini SA, Shahshahani S, Karimlou M, Tabatabai Ghomsheh F. The Effect of the combination of active vestibular interventions and occupational therapy on Balance in Children with Bilateral Spastic Cerebral Palsy: A pilot randomized controlled trial. Iran J Child Neurol. 2020 Fall;14(4):29-42.
- ↑ 29.0 29.1 29.2 29.3 29.4 29.5 29.6 29.7 29.8 Sensory Integration. Available from https://www.cerebralpalsy.org/about-cerebral-palsy/treatment/therapy/sensory-integration-therapy [last access 13.02.2024]
- ↑ 30.0 30.1 Novak I, Mcintyre S, Morgan C, Campbell L, Dark L, Morton N, Stumbles E, Wilson SA, Goldsmith S. A systematic review of interventions for children with cerebral palsy: state of the evidence. Developmental medicine & child neurology. 2013 Oct;55(10):885-910.
- ↑ Novak I, Morgan C, Fahey M, Finch-Edmondson M, Galea C, Hines A, et al. State of the evidence traffic lights 2019: systematic review of interventions for preventing and treating children with cerebral palsy. Curr Neurol Neurosci Rep. 2020 Feb 21;20(2):3.
- ↑ Mahaseth PK, Choudhary A. Sensory integration therapy verses conventional physical therapy among children with cerebral palsy on gross motor function–a comparative randomized controlled trial. Annals of the Romanian Society for Cell Biology. 2021 Apr 30:17315-34.