Sensory Processing & Integration

8 total senses:

• Touch/Tactile: light touch, deep pressure, pain, temp, texture, size/shape

• Interoception (receptors in organs): hunger/fullness, hot/cold, thirsty, nauseous, itchy

• Proprioception (receptors in joints/muscles): body in space awareness, perception of body position

• Vestibular (receptors in the inner ear): sense of movement (consistently partners with visual system)

  • Good way to test system: a standing balance with open eyes v. closed eyes

• Smell

• Sight

• Taste

• Hearing

Motor neurons: cary information from different areas of the nervous system & are divided into two categories

• Upper motor neurons: carry motor messages from primary motor cortex to:

  • cranial nerve nuclei

  • interneurons in the ventral horn

    • up to the ventral horn & synapses with interneuron that connects to motor cell body

  • Considered part of the CNS

• Lower motor neurons: carry messages from motor cell bodies in the ventral horn to the peripheral skeletal muscles

  • examples of LMNs are cranial nerves, spinal nerves, cauda equina, & ventral horn

  • Considered part of the PNS

Input --> Sensory Integration --> Output

• Senses 

• CNS

  • register

  • orient

  • select

  • integrate

  • analyze

  • organize/plan

  • output/decide

• Result

  • perception of body/world

  • adaptive responses 

  • learning process

• when environmental stimuli are processed & organized effectively --> goal directed action on the environment (adaptive response)

  • adaptive responses are the correct way of responding but it requires successful integration of inputs

• the more adaptive responses a child has that are successful, the more sensory integration that occurs (more organized state, more risk taking, more learning)

• child must be actively involved --> creates more motivation & episodic memories

Sensory Discrimination & Perception

• Sensory discrimination & perception --> accurate perception & interpretation of visual, tactile, proprioceptive, & vestibular info

  • eye, hand, body coordination

  • meaningful praxis

  • posture

  • accurate use of force & strength

• Tactile discrimination & perception

  • frequently associated with proprioceptive & visual perception impacts

    • grasp pattern

    • finger isolation & movements

    • finger-thumb opposition

    • motoric effort & accuracy

    • praxis - sequencies, planning, execution of tasks

• proprioceptive perception impacts

  • too much or too little force exertion

  • clumsy/awkward movements

  • uncoordinated

  • may seek deep pressure or joint compression

• vestibular discrimination impacts

  • bilateral coordination

  • postural-ocular control

• visual perception

  • visual-spatial perception

  • visual memory

• auditory perception

• Sensory modulation (reactivity/responsiveness) --> 

  • appropriate responses to environmental stimuli

  • activity level

  • behavior

  • emotional regulation

• Under-responsiveness & low sensory registration (hyporeactivity)

  • child does not notice or register environmental stimuli

  • leads to:

    • low or high arousal level

    • low tonicity

    • does not respond to sensory input because they are not getting enough of it--> safety issues

    • postural issues

• Over-responsiveness & sensory defensiveness (hyperreactivity)

  • leads to:

    • avoidance, discomfort, distractibility, OCD, anxiety

    • tend to want to control the stimuli/input

  • tactile defensiveness

    • avoidance of textures 

    • picky or restrictive eating

    • avoidance of people & crowds, especially those with other children because they cannot predict their movements & the potential of touching them

    • what to do?

      • deep pressure override

      • visual override

      • mentally prep

  • gravitational insecurity - sign of hypersensitivity to vestibular input

    • nervous when feet leave the ground

    • scared of heights

    • anxious with backwards or vertical linear movement

    • can lead to nausea with motion

  • auditory defensiveness (sensitivity) 

    • avoidance of noise or crowds

    • reduced socialization

    • on-going dysregulation

• Sensory-based postural issues --> bilateral coordination

• SBPI --> poor trunk stability, righting & equilibrium reactions, trunk rotation, oculo-motor control

  • vestibular

  • proprioceptive

  • visual

• AKA: vestibular-bilateral integration & sequencing

• vestibular problems lead to:

  • inefficient balance & equilibrium reactions

  • bilateral coordination

• Assessments

  • balance

  • bilateral coordination

  • prone extension

  • PRN (post-rotary nystagmus)

When having a kiddo with difficulties related to praxis, breaking down the planning to identify which area (ideation, motor planning, or execution) is affected

Praxis:

• Ideation: conceptualize movements 

• Motor planning: plan movement

• Execution: execute movement

Dyspraxia: difficulty with motor planning & "ideation"

• clumsy, awkward movement

• inefficient movement

• difficulty transitioning from one position to another

• timing/sequencing

OT's must determine what is typical and what is maladaptive that impacts functioning

1. generate more input for weak processing of sensation

• provides more feedback to senses that need more input for understanding the environment around the child

2. regulate arousal

• system needs more feedback since the entire system is under-aroused

3. modulation (over- or under-responsiveness)

• seek sensation to dampen over-responsive sensory system

4. limited praxis (NOT sensory-seeking) - 

• if there is limited praxis, but child is still sensory seeking, it signals there is a greater relation of components of praxis rather than the sensory inputs they receive

• these are kiddos that watch others do it first and then try

• if a child doesn't know how to play creatively with novel items, they will be more repetitive with their behaviors

5. temperament (NOT sensory issues

• AOTA's initiate to support practice that is evidence-based, non-duplicative, and without harm

• OT should determine if sensory integration is an issue with a standardized assessment before planning to address it

  • Don't provide sensory-based interventions within documented assessment results of difficulties processing or integrating sensory information

  • primarily focused on using functional & purposeful interventions

Basic Assumptions

• sensory input can be used systemically to elicit an adaptive response

• registration of meaningful input is necessary before an adaptive response can be made

• an adaptive response contributes to the development of sensory integration

• better organization of adaptive responses enhances the child's general behavioral organization

• more mature and complex patterns of behavior emerge from consolidation of simpler behaviors

• the more inner-directed a child's activities are, the greater the neural organization

Fidelity Elements for ASI

• ensures physical safety

• presents sensory opportunities

• supports sensory modulation and a regulated state

• challenges postural, ocular, oral, & bilateral control

• challenges praxis

• collaborates in activity choice

• just-right challenge

• activities are successful

• supports child's intrinsic motivation to play

• therapeutic alliance with the child

Outcomes of ASI

• increase frequency/duration of adaptive responses

• develop more complex adaptive responses

• improve fine/gross motor skills

• improve cognitive, language and academic performance

• increase self-confidence and self-esteem

• enhance occupational engagement & social participation

• enhance family routines

Assessments

• interviews & questionnaires (SP-2, SPM)

• natural observations

• structured observations (Ayres clinical observations)

• standardized tests (QNST, COMPS, EASI, SIPT)

Sensory Integration Praxis Test (SIPT):

• latest edition - 1989

• developed by A. Jean Ayers

• consists of 17 subtests that look at various areas of sensory & praxis

• normed on 2,000 children 

• designed for kids 4-8 yr

• requires additional training & certification

Evaluation in Ayers Sensory Integration (EASI):

• Developed in 2023

• requires specialty certification

• added 3 additional areas from the SIPT, to create 20 subtest = lengthy

• normed on kids internationally (100+ countries)

• designed for kids 3-12 yrs

• similar to SIPT with more advancements

Clinical Observation of Motor & Postural Skills (COMPS):

• screening tool - takes 5-15 mins to administer

• no specialty certification required

• consists of 6 subtests related to motor & postural skills (e.g. supine flexion)

• Focuses on sensori-motor functioning, cerebellar fx, postural control (stability), motor coordination (mobility), motor planning, sequencing 

• used when data is needed - great norms 

• normed for kids 5-15 yrs

Quick Neurological Screening Test (QNST):

• screening test for neurological signs - take 20-30 mins

• no specialty certification required

• consists of 14 subtests

• used for ages 4-80+

• criterion-referenced - no standardized data

Structured Observations of Sensory Integration (SOSI-M):

• takes 20-40 mins

• designed for ages 5-14 yrs

• includes 14 subtests

Providing Sensory Interventions

• work with teams to select appropriate sensory tools

• train teams on use, cleaning & purpose

• collect data on outcomes

• make adjustments to the interventions/plan (based on the data)

Sensory Stimulation Protocols

• Not considered ASI because the therapist implements the protocol but does not make ongoing modifications to the degree or quality of the input based on the child's adaptive responses

• strategies tend to be passive - influences neuroplasticity

• can be used in conjunction with ASI if fidelity principles are followed but use with caution

  • Massage

  • sound-based interventions

  • Wilbarger protocol (Wilbarger Deep Pressure and Proprioceptive Technique (DPPT)

    • therapeutic approach designed to help individuals with sensory defensiveness by using specific brushing and joint compression techniques

  • Astronaut program - links oculo-vestibular systems together

  • weighted vest/materials & compression

    • Short term calming effect

    • Allows child to engage in functional activities to develop skills in the moment for carryover later

    • Reduces sensory defensiveness, anxiety and arousal

  • Grandin hug machine - 

Sensory-based Strategies

• sensory strategies

• individual training

• groups

• modifications

• sensory diet/programs