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Perceptual Motor Development

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Perceptual Motor Development Powered By Docstoc
					Theories of Motor Behavior




           Central Nervous System
           Sensorimotor Disorders
CNS: Spinal Cord

Tracks for Sensory and Motor Impulses
Dorsal Ascending Sensory Tracks
  Afferent


Ventral Descending Motor Tracks
  Efferent
  CNS: Brain
 Brain Stem
    Postural Tone / Reflexes
    Attention and Arousal
    Filter
 Reticular Activating System
  (RAF)
    Reciprocal Innervation
    Filter
 Midbrain
    Stability
    Sensory info from Eyes
 CNS: Brain
 Cerebellum (“Little
  Brain”)
  Relay Center
  Kinesthetic and
   Vestibular Input
  Subcortical / Automatic
   Movements
 Thalamus
  Relay Station
  Arousal
CNS: Brain

 Cerebrum
 Two parts:
  Cortex and
  Internal Capsule
  Cortex : Higher
   level Functions
  Capsule: Limbic
   System
Theories That Guide Practices

Maturation Theory
Dynamic Systems Theory

Hierarchical Levels of Function Theories
  Neurodevelopmental / Neurophysiological Theory
  Sensorimotor / Sensory Integration Theory
Sensory Integration




          Understanding Theory and
                          Practice
Nervous System 101

 Central Nervous System – Brain and Spinal Cord
      Peripheral Nervous System - contains only nerves and connects the brain and
       spinal cord (CNS) to the rest of the body
          Autonomic Nervous System – contains Sympathetic and Parasympathetic Systems
   Sympathetic Nervous System – “Fight or Flight”
   Parasympathetic Nervous System – “Rest and Digest”
   Neurotransmitters
   Sympathetic response causes increase in Cortisol
   Parasympathetic response increases Serotonin and Dopamine
   Serotonin – safety/satisfaction – helps regulate input
   Dopamine – focus/attention
   Cortisol – stress chemical that uses up Serotonin
   Lack of Serotonin – impulsive behavior / depression
   Release Serotonin – Pressure/Vestibular Movement/Proprioception
   Release Dopamine – Touch/Proprioception
   Specific movements can serve to release the proper neurotransmitters if
    there is a deficiency – This is where intervention comes in!
Hierarchical Levels of Function Theory


Definition: Development is spiral with
 the integrity of each system built on the
 sound functioning of the system
 immediately below it. The nervous
 system must be integrated at lower
 levels before cognitive approaches like
 watching demonstrations and listening
 to directions can be successful
Hierarchical Levels of Function Theory

Lowest part of the brain – Brain Stem
  Integration
    Visual (vision) [midbrain]
    Auditory (hearing)
    Vestibular (balance/head movements)
    Proprioceptive/Kinesthetic (body sense)
    Tactile (touch)
    Olfactory (smell) [cortex]
    Gustatory (taste)
Highest part of the brain – Cortex
(Higher order processing)
Introduction to Sensory Integration

Sensory Integration – “putting sensory
 information to use”
How do we “put sensory information to
 use?”
Sensory Info – brain stem (except?)
  3 choices
Properly working brain stem
Introduction to Sensory Integration

What types of basic sensory information
 do we get?
  Vision
  Auditory
  Proprioceptive/Kinesthetic
  Tactile
  Vestibular
 Introduction to Sensory Integration
 Proprioception/Kinesthesis – is information from the
  body about where the body is in space without
  vision.
  Receptors
      (muscle spindles, golgi tendon organs, golgi type receptors,
       ruffini endings, modified pacinian corpuscles, cutaneous
       receptors, vestibular semi circular canals)
 Tactile: uses the cutaneous receptors to give
  information about touch (light/deep).
 Vestibular: uses vestibular semi circular canals to
  register head movements.
 Balance: requires the integration of 3 sensory
  systems (vision, vestibular, and proprioceptive or
  somatosensory)
Introduction to Sensory Integration

 In a properly working brain, most of the sensory
  information we get from the environment is
  inhibited at the brain stem.
 In children with sensory integration disorders,
  some sensory information is not inhibited or
  enhanced (sent up to the cortex) properly
  visual, vestibular, tactile, proprioceptive, or auditory
 When a child is not “integrating” one of the
  sensory information systems (e.g. vestibular),
  then they are said to have a vestibular
  integration problem. Sensory integration is a
  broad term that encompasses all of the
  aforementioned sensory systems (1-5).
Introduction to Sensory Integration

When children do not “integrate” properly,
 learning is compromised. Behavior may
 be compromised as well. The key is to
 identify which sensory system or systems
 the child is have difficulty with, and
 remediate accordingly.
We do not treat the symptom; rather we
 address the underlying neuropathology.
Introduction to Sensory Integration

 This process is called sensory integration
  therapy/training. It is based on hierarchical
  levels of function theory.
 Remediation
 Children with sensory disorders will typically
  display behavior that indicates a possible
  integration problem. This is called sensory
  integration dysfunction, sensory integration
  disorder, or sensory processing disorder.
 For all practical purposes, these terms are
  synonymous.
Sensory Integration Dysfunction (SID/DSI)
Sensory Processing Disorder (SPD)

Put simply, what is sensory integration
 dysfunction?
It involves concepts such as modulation,
 registration, hyper/avoiding, hypo/seeking,
 integration, various sensory systems, and
 levels of severity (mild, moderate, severe)
Sensory Integration Dysfunction (SID/DSI)
Sensory Processing Disorder (SPD)

 For the most functional understanding, you should know:
 Children will either seek (sometimes called aggressive)
  sensory input or avoid (sometimes called defensiveness)
  sensory input or not register sensory input (sometimes
  called under-registration)
 Certain behaviors will be associated with the particular
  disorder/dysfunction
 Mild disorder will typically not affect life’s functions
 Severe disorder will need intervention because it will
  impact, school, social, and home life (pervasive).
What it feels like: Examples
 Visual – fluorescent lights (may perceive the cycling of
  the lights – feels like being in a strobe light – similar to
  an old flickering light bulb – how could a child sitting in a
  chair concentrate?)
 Auditory – vacuum cleaner or birds chirping (may sound
  like fingernails on a chalk board)
 Gustatory – strong tasting food (may taste like battery
  acid)
 Olfactory – perfume (may be like taking a deep breath
  from a bleach bottle)
 Tactile – light touch (may feel like someone is touching
  an open wound)
 Proprioceptive – coordinated movements (like a bull in a
  china shop)
 Vestibular – Stand up!
Food for Thought
 All individuals need to move. The younger the
  individual, the more frequently this “need” to
  move is necessary.
 Ask yourself, “How long can I pay attention to
  the most incredible speaker without needing a
  break”?
 Children need “breaks” too. The age of the child
  is inversely proportionate to their need to have
  “movement breaks”.
 What is a sensory diet?
 “Hideouts” vs. “Time outs”
Sensory Integration Dysfunction:
Activities for Remediation
 Ten modalities provide sensory input that must be
  organized and processed. They include: touch and
  pressure; kinesthesis; vestibular; temperature; pain,
  smell; taste; vision; auditory; and common chemical
  sense. Each modality has a special type of end organ
  (sensory receptor) that is sensitive to only certain stimuli,
  and each has a separate pathway from the receptor up
  the spinal cord to the brain. Most important to motor
  learning are tactile, kinesthetic, vestibular, and visual.
  When these systems exhibit delayed or abnormal
  functioning, motor development and/or learning is
  affected.
Sensory Integration Dysfunction:
Activities for Remediation
Tactile Integration
Probably the most fully developed
 resource at birth. The brain organizes
 tactile system input in many ways and has
 different locations for processing light
 touch, deep pressure, cold, heat, and
 different kinds of pain that originate in the
 skin receptor organs. Of particular
 interest:
    Tactile Integration
   Tactile Defensiveness (avoiding): Touch (one’s own and
    that of others) causes generalized discomfort, irritability, or
    temper outbursts.
       Behaviors:
           Stiffening when tactile praise (e.g. shoulder touch or pat on the back is
            given); ducking or moving aside to avoid a hug or tactile praise
           Complaining more than peers about feeling dirty or sweaty or hot or
            cold, or showing distaste through gesture or facial expression
           Avoiding tight clothes, shoes, gloves, automobile seat belts, elevators
            full of people, and other variables that increase tactile input
           Disliking certain food textures, unusual sensitivity to these
           Complaining that peers tag too hard in games or push too much in lines;
            inability to cope with normal roughhousing among peers
   Note: These behaviors might be specific to certain body
    parts or might occur in response to touch anywhere on the
    body.
    Tactile Integration
   Tactile Craving or Aggressiveness (seeking): A
    greater than average need to touch or be touched.
       Behaviors:
           Need to touch repeatedly those surfaces and textures that
            provide soothing and comforting tactile experiences
           Seem compelled to touch certain surfaces and textures that
            cause other people discomfort (nail biting, skin picking, skin
            biting)
           Seek certain messy experiences, often for long durations
           Enjoy vibration or movement that provides strong sensory
            feedback
           Prefer extra spicy or excessively sweet foods
           Uses mouth to explore objects (after age of 2)
Tactile Integration
 Tactile Hyposensitive (under-
  registering): Not responsive to touch
  [within the norm].
   Behaviors:
     Seem unaware of touch unless it is very intense
     Be unaware of messiness on face
     Show little or no reaction to pain from scrapes,
      bruises, cuts, or shots
     Hurt other children or pets during play, not
      comprehending the pain others feel
     Fail to realize that they have dropped something
  Tactile Integration: Activities for
  Remediation
For tactile defensiveness (avoiding):
 Use massage, either by hand or vibrator, to activate deep pressure
  receptors. Massage can be by another or by self. Encourage stroking or
  rubbing of own body parts. The back of the hands and forearms are the
  least defensive and thus constitute the first progression activity when
  severe tactile defensiveness is present.
 Stroke or brush body parts with fabrics and brushes of different textures.
  Coarse or rough textures are more easily tolerated than smooth textures,
  so build the teaching progression from coarse to smooth. (Do not brush
  stomach, head, neck, face, or chest). (see Protocol)
 Joint compressions (see Protocol)
 Introduce weights of different textures as part of touch-feel-lift
  progressions in weight-lifting units. Stuffed animals are good with young
  children; use hug-and-release movements as well as touch-and-lift.
 Use below (seeking) activities on an as tolerable and increasing basis
   Tactile Integration: Activities for
   Remediation
For tactile craving (seeking) and under-registering:
 Can use above activities for additional tactile input
 Playing in multiple textures (play dough, shaving cream, gak,
  rice, beans, bird seed, painting).
 Conduct activities with a reach-in-grab bag or box that
  require guessing the object one is touching without use of
  sight. Have children run from one station to another where
  different touch-and-guess activities are done.
 Conduct “blind person bluff” type games in which blindfolded
  persons tries to catch and identify others.
 Squeezing a squish ball or balloon filled with sand (can
  attach to belt)
Proprioceptive/Kinesthetic Integration


Gives us information from the body about
 where the body is in space without vision.
 Provides input that helps us with
 perception of sensations from touch and
 movement (both external and internal). Of
 particular interest:
  Proprioceptive/Kinesthetic Integration

 Proprioceptive Defensiveness (avoiding):
  resists input into the joints either by
  compression or traction.
   Behaviors:
     Avoid putting weight onto their joints such as when
      standing, pushing things or jumping
     Complain about lifting heavy things
  Proprioceptive/Kinesthetic Integration

 Proprioceptive Craving or Aggressive
  (seeking): attempts to get needs met by
  seeking out proprioceptive input.
   Behaviors:
     Kick heels against floor or chair
     Bumps and crashes into objects
     Stomp or slap feet on ground when walking
     Wants shoelaces, hoods, and belts to be tightly fastened
     Chew constantly on objects like shirt collars and cuffs,
      hood strings, pencils, toys, and gum
     Likes to tackle people and dive into leaf piles
Proprioceptive Integration: Activities
for Remediation

For proprioceptive defensiveness
 (avoiding):

  Brushing – follow protocol
  Joint Compressions – follow protocol
    Proprioceptive Integration: Activities
    for Remediation
 For proprioceptive craving (seeking) and under-registering:
       Wheelbarrow walking
       Jumping rope
       Trampoline jumping
       Throwing/carrying heavy objects (bean bags)
       Pushing/pulling weighted toys/objects
       Hopping
       Jumping off curbs/apparatus
       Climbing up the down part of slide
       Swimming
       Raking
       Tug of war
       Climbing rope ladders or ladder swings
       “Smushing” with cushions
       Wearing wrist or ankle weights or weighted vest
        Squeezing a squish ball or balloon filled with sand (can attach to belt)
       Extension activities. (Activate receptors by changing tension). Any movement involving
        prolong contraction of extensor muscles against gravity (e.g. scooterboard activities done
        in prone position with head up – heightens awareness of midline)
 Vestibular Integration
 The vestibular system originates in the inner ear
  area of the temporal lobe, where hair cell receptors
  take in information about the position of the head
  and all its movements, however subtle. This
  information, when interpreted and acted upon by
  other parts of the brain, helps to maintain static and
  dynamic balance. The vestibular system is the
  most important structure in the regulation of body
  postures. It prevents falling, keeps body parts
  properly aligned, and contributes to graceful,
  coordinated movement. Additional vestibular
  system functions: gravitational security, muscle
  tone, auditory-language processing, visual-spatial
  processing, and motor planning.
    Vestibular Integration
   Vestibular Defensiveness (avoiding):
       Behaviors:
           Dislikes playground activities, such as swinging,
            spinning/sliding
           Cautious, slow moving, and sedentary, hesitating to take risks
           Uncomfortable in elevators/escalators, motion sickness
           Gravitational insecurity (fear of falling when no danger exists,
            fearful of heights, even slightly raised surfaces, become
            anxious when feet leave ground, fearful climbing stairs, feels
            threatened when head is inverted, upside down or tilted [ex.
            titling head back for shampoo])
           Easily looses balance
           Moves in awkward, uncoordinated way
           Hesitates or declines to join in physical activities
           Has social/emotional problems
  Vestibular Integration

 Vestibular Craving (seeking):
   Behaviors:
     Need to constantly move in order to function
     Has trouble sitting still or staying in a seat
     Repeatedly and vigorously shakes head, rocks back and
      forth, and jumps up and down
     Craves bouncing, swinging, spinning, going upside down
     Seeks out fast spinning rides/structures
     Does not get dizzy, even after spinning rapidly for long
      periods of time
     More than other children, crave trampolines, seesaws and
      teeter totters
    Vestibular Integration: Activities for
    Remediation
 For vestibular defensiveness (avoiding): Use stable surface to stand or sit
  on. Head should be aligned forward facing with shoulders
     Slow rhythmic activities – linear movement (back and forth)
     Slow rocking in prone position on a Physioball
     Brushings and Joint Compressions
 For vestibular craving (seeking) and under-registering:
       Swinging
       Prone scooter board
       Somersaults
       Sit and Spin
       Trampoline
       Going upside down
       Rocking horse
       Hippity Hop
       Bouncing on a Physioball
       Teeter totter
       All the activities they like to do!
Visual Integration
 The visual system is comprised of many subsystems,
  some reflexive and some voluntary. All are important in
  postural control and motor performance. The many
  subsystems can be organized into two types of vision:
  (a) acuity and (b) eye coordination. Acuity – refractive
  vision. Refractive problems: myopia (nearsightedness),
  hyperopia (farsightedness), and astigmatism (blurring
  and distortion). Eye Coordination – activity of the six
  external muscles of the eyeball. Binocular coordination
  – both eyes working together to form a picture.
  Problems: strabismus (cross eyed) and nystagmus
  (constant, involuntary movement of the eyeballs).
Visual Integration
 When vision problems are suspected, an
  ophthalmologist should be consulted. Refractive
  problems are treated with prescriptive glasses or
  surgery. Strabismus can also be treated with
  surgery.
 The best way to enhance vision for body control
  is to provide lots of practice in many and varied
  movement tasks. The breakdown in vision
  typically is not exclusively a problem of the eyes
  but rather the complex process of integrating
  inputs from several sensory modalities and
  translating them into appropriate motor outputs.
   Visual Integration: Activities for
   Remediation

 Use suspended-ball activities in which the height of the ball is
  periodically changed so the head and eyes must practice
  accommodations
 Do lying and locomotor activities on tables of different heights
  so that eyes look down and accommodate. When appropriate,
  switch from table to wide balance beams
 Practice object handling from many positions: midline and
  looking up, down, and sideways. This includes prone-supine-,
  and side-lying down on mats as well as on apparatus of
  different heights and tilts to give looking downward new
  perspectives
 Practice with (a) the body stationary, (b) the body in
  locomotion, and (c) the body moved by external forces like
  swings, balance boards, scooterboards, merry-go-rounds,
  escalators, treadmills, and the like.
Deep Pressure Brushing and Joint
Compression Protocol
*When beginning the brushing and joint compression
  protocol, please monitor the student for any adverse
  reactions up to two weeks after starting the protocol.
  Report any adverse reactions to your occupational
  therapist or physical therapist
 Why: Brushing stimulates the skin’s deep pressure
  nerves and joint nerves to help organize the nervous
  system. It appears that if the brushing is applied
  consistently over time, it helps reduce and at times even
  eliminate tactile defensiveness. Brushing is also used to
  help with organization and attention.
 What: Use a soft surgical scrub brush (from PDP
  products). A terry-cloth towel may be used for infants
Deep Pressure Brushing and Joint
Compression Protocol
 How: This process should take about two minutes:
    Start by brushing first the arms, hands, then the back, then the
     legs and feet
    Use FIRM PRESSURE to brush on arms, hands, back, legs and
     feet
    Use long, smooth strokes, typically 10 strokes per limb & back
     (up & down is on stroke)
    Begin from proximal to distal (top to bottom) with the brush at a
     horizontal angle. Pressure should be firm enough to bend the
     bristles of the brush all the way over and all the way back during
     the opposite stroke (Do not scrub!)
    Brushing bare skin is preferred. If brushing over clothing, the
     brush may be turned to a vertical angle
    Palms and soles of feet are sometimes brushed. Typically when
     doing small areas like the hands and feet, go back and forth over
     the area 3 times and move on
Deep Pressure Brushing and Joint
Compression Protocol
 How:
  Brushing is followed by GENTLE JOINT
   COMPRESSION, 6 – 10x to the shoulders, elbows,
   wrists, hips, knees, ankles, and sometimes fingers and
   feet. AVOID ALL LIGHT TOUCH. No brief touch or
   light brushing is used
  Joint compression to the shoulders, elbows and wrists
   may be substituted with pushing the palms of the hands
   together or pushing against a wall (wall push-up). Joint
   compression to the hips, knees, ankles and toes may be
   substituted with jumping. Be sure to have the child land
   flat on feet versus toes
  DO NOT brush the stomach, head, neck, face or chest
Deep Pressure Brushing and Joint
Compression Protocol
 When: Brushing has an effect on the nervous
  system for 90 minutes to 2 hours. Often times it
  is used the first thing in the morning, before
  school, before a specific concentrated task and
  before going out to stimulating environments.
  Brushing and joint compressions can be
  repeated every two hours.
 PRECAUTIONS:
  Skip over any sores, cuts, rashes, etc.
  Never brush the stomach, head, neck, face and chest
  Report any unexpected responses
  Consider joint problems with the joint compressions
  NEVER BRUSH A CHILD UNDER 2 MONTHS OF AGE
Mirror Neuron Systems
           New Research
    Mirror Neuron Systems
 Specific subsets of neurons (called Mirror Neurons) are
  activated when an individual performs certain actions
 These same neurons activate when the individual
  observes others performing the same movements
 Implication: “mirror neurons provide a direct internal
  experience and therefore understanding, of another
  person’s act, intention or emotion” (Rizzolatti, et al.,
  2006 pg. 58)
 Intention of an action is significant factor in which mirror
  neurons (specific to different areas of the brain) are fired
 Mirror neurons respond strongly to the intention of an act
   Ex. Monkey’s action of grasping – depending on final
    goal, mirror neurons fire differently (more strongly to
    understood goal)
Mirror Neuron Systems
Emotions
 Disgust
    Ex. when observing disgust on the face of someone else – mirror
     neurons in the anterior insula are activated
    The observer and the observed share a neural mechanism that
     enable a form of direct experiential understanding
    This may represent a physical neural mechanism for empathy that
     permits the understanding of emotions in others
 Pain
    Ex. When feeling pain or witnessing pain in others, the anterior
     insula and anterior cingular cortex mirror neurons activate
 This may provide a neural basis for interpersonal
  relationships on which more complex social behaviors are
  built – allowing us to empathize with others
Autism and Mirror Neuron Systems
 Mirror neurons may be involved in empathy and
  the perception of another individual’s intentions
 Mirror neurons are involved in the interpretation
  of complex intentions
  Inferior Frontal Gyrus (movement guidance and
   assessment of intentions of others)
 Mirror neurons allow our brain to mentally
  simulate others actions
 Individuals with Autism have dysfunctional mirror
  neuron systems
  Mu WAVE suppression on EEG in premotor cortex
Autism and Mirror Neuron Systems
 Characteristics of Autism that may be explained
   by dysfunction in the mirror neuron system
Characteristics
1. Deficit in ability to construct a “theory of other
   minds” (Frith & Baron –Cohen) – Empathy
2. Difficulty imitating others
    Dysfunction in mirror neurons of the Anterior
     Cingulate Cortex (regulation of empathy and other
     emotions)
3. Difficulty interpreting metaphors
    Requires cross domain mapping (Angular Gyrus)
    Bouba / Kiki Test
Autism and Mirror Neuron Systems
Autism and Mirror Neuron Systems
 The limbic system triggers the autonomic nervous
  system – preparing the body for action
    Ex. Fear – heart rate increases and body sweats
 The ANS arousal in turn provides the brain with
  feedback amplifying the emotional response – thus
  creating an emotional map of the emotional significance
  of the individual’s environment (Salience Landscape
  Theory – Ramachandran & Oberman, 2006)
 Individuals with autism may have a distorted salience
  landscape
 Distorted perceptions of emotional significance may
  explain:
    Inappropriate social responses to events
    Intense preoccupation with ex. train schedules
    Looking away during normal conversation to reduce stress

				
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