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Shantel Bishoff

Touro University Nevada

CASE STUDY

Practice Setting

Physiotherapy Associates
Childrens Therapy Center
Pediatric Outpatient
Rehabilitation Center
Comprehensive program for

pediatric population ages


birth-21 years
45-60 minute treatment
sessions
Tailored programs for
children with motor control
problems, physical
disabilities & sensory issues

Bishoff, Shantel. Sensory Gym." 2014. JPEG file.

Meet Ethan
7 year old, male
Lives with biological parents
and younger sister
Attends John F. Miller School
Receives OT services 2x/wk
Severe low blood sugar levels
caused seizures at 2 days old
Diagnosed at 9 months old
Lennox Gastaut Syndrome
Cerebral Palsy
Generalized nonconvulsive
epilepsy, with intractable
epilepsy
Cortical Blindness
Developmental Delay

Retrieved from https://www.facebook.com/pages/EthansJourney/471216282932228

Prognosis
Lennox-Gastaut

syndrome is a severe form of epilepsy. It includes various


seizure types such as: tonic, atonic, atypical absence, and myoclonic. There
may be periods of frequent seizures mixed with brief, relatively seizure-free
periods. Most children with Lennox-Gastaut syndrome experience some
degree of impaired intellectual functioning, along with developmental delays,
and behavioral disturbances.

Some children will later have fairly good seizure control

Others will continue to have multiple types of poorly controlled seizures


throughout life

The intellectual and behavioral development


of children whose seizures are frequent and
are given high doses of more than one drug
may be severely delayed.
Management
Ketogenic diet
Vagal stimulator

(Crumrine, 2002)
Retrieved from http://www.lgsfoundation.org/presskit.html

Model of Practice I
Person, Environment, Occupation, Performance (PEOP)
Founded by Law, et al. (1995)
Revised by C. Christiansen & C. Baum (1997)

Retrieved from: http://cb3e.slackbooks.com/

Initial Evaluation
Functional Tests

ADL/Function

Dependent for all ADLs; tolerates HOH assisted feeding


Max A for functional mobility

Cognitive

Impaired visual motor integration/perception


Minimal direction following
Flat affect
Non-verbal
Minimal eye contact

Developmental

Delayed FM skills: utensil grasps, pinch and grasp


patterns, object manipulation, hand to hand, midline,
dexterity, and WB skills
Decreased interest in age-appropriate cause/effect toys

Motor Development

Demonstrates delays
Requires HOH A for FM tasks and Max A for GM tasks

Initial Evaluation
Functional Tests
Observations

Behavior: Decreased level of alertness & arousal, decreased


initiation and follow through of purposeful activities;
aggressive
Tone: Base of low tone, however, functional;
Balance/equilibrium: fair
UE protective extension: Delayed/impaired
Trunk righting: Fair

Sensory Assessments

Tactile: Decreased registration & interpretation of tactile


input. Minimal hand use in self-feeding. Decreased tolerance
and engagement with HOH A and therapist directed hand
manipulation, touch and object play. Increased anxiety when
presented with tactile input in play and self-care challenges.
Sensory Processing: Impaired multi-sensory processing
skills
Vestibular: Decreased vestibular and kinesthetic awareness
Proprioceptive: Decreased modulation of self during
proprioceptive-based activities. Decreased safety and body
awareness skills.

Impairments Identified

Max sensory defensiveness


Impaired sensory modulation
ability
sensory
integrative/processing skills
Impaired behavior and social
skills
visual motor/visual perceptual
skills
Impaired oral
motor/sensorimotor based
feeding skills
I with ADLs

fine/gross motor
developmental status
grasp/prehension skills
trunk/proximal
stability/strength
postural skills
Impaired equilibrium and
righting reactions
UE strength
distal hand/finger strength
muscle tone
auditory processing/verbal
command following skills

Person
Intrinsic Factors

Physiological
Abnormality /disruption
of brain development
Lethargy
Lack of coordination
Decreased muscle
endurance
Decreased motor
planning
Sensory defensiveness

Cognitive
Developmental Delay
Intellectual Disability
Impaired cognition
Decreased safety
awareness
Decreased executive
functioning
Decreased attention

Person

Intrinsic Factors

Psychological
Temperament/
aggressive
Anxiety
Socially avoidant
behavior
Spiritual
Family values
Collaboration

Neurobehavioral
Drop seizures
Impulsivity
Ataxia
Encephalopathy
Flat affect
Drowsiness

Retrieved from https://www.facebook.com/pages/Ethans-Journey/471216282932228

Environment
Extrinsic Factors

Natural environment
Consistent warm climate
Four concrete steps leading to
entry way of SS home decreasing
safe ambulation
Flat terrain
Built environment and technology
Physiotherapy sensory gym
Vestibular swings
Ball pit
Mats
Rock wall
Proprioceptive-based
surfaces
Deep pressure
pillows/vests/blankets/
sensory tunnels

Social supports
Close-knit family
Supportive school system
Economic systems
Limited tx hours due to insurance
coverage
Decreased ability to obtain
necessary medications
Person culture and values
Family support and collaboration
throughout tx process
Facility culture and values
Rehab goals based on
parent/therapist collaboration
Treatment focus on sensory
integration

Occupations

Big
Brother
Retrieved from
http://blogs.olin.edu/studentblog/2014/11/webought-a-ball-pit.html

Retrieved from http://takedesigns.com/horsepictures/

Son

Retrieved from
http://www.libraries.wright.edu/community/outofthebox/2013/10/22/servicedog-in-training-at-the-archive/

Retrieved from terapimarketi.com

Friend

Occupational Performance
Strengths

Barriers

Strong family support and

involvement
Interventions tailored
toward primary interests
Appropriate and effective
facility equipment to meet
specific needs
Increased participation with
deep pressure input
Animal therapy clinic
New 4Paws4Ability dog
owner

Limited treatment time


Decreased ability to

communicate
Neurobehavioral symptoms
Drop seizures
Anxiety
Cortical blindness

Occupational Performance
STG/LTG

Improve self-help skills

Tolerate vestibular activities to facilitate organization of self, registration


and modulation, attention to task, decrease impulsivity, increase
frustration tolerance, increase verbal and direction follow-through

Engage in challenging motor planning activities to facilitate appropriate


skills and safety awareness

Tolerate sensorimotor activities to facilitate tolerance to therapist


activities, direction and structure to engage appropriately in tasks

Demonstrate tolerance to directed tactile activities to facilitate improved


tactile discrimination, body awareness, sensory processing, and fine
motor skills

PEOP Intervention Process


Guidelines of intervention
process in the PEOP
Model

Appreciation of the restorative


benefits of occupational
performance
Identification of the importance
of environments in which a
client functions
Adaptation and modification of
the occupation to fit the clients
abilities
Enhancement and expansion
of the role functioning and
acquisition

Intervention
Implementation

HOH A to adapt to clients


abilities with FM tasks
Utilizing rotary movement vs.
linear movement on sensory
swing to increase attention
due to preference
Collaboration with client/family
to increase success

(Baum & Christiansen, 2005)

Model of Practice II

Sensory Integration Theory (SIT)


Brain behavior relationships
Developed by Jean Ayres in the 1960s
Ayers (1972) defined sensory integration as the
neurological processes that organizes sensation
from ones own body and from the environment
and makes it possible to use the body effectively
within the environment

Retrieved from http://asensorylife.com/sensory-modulation.html

(Ayres, 2005)

Sensory Integration

Primary assumptions
The three major postulates of sensory integration theory
are:
o 1. Learning is dependent on the ability to take in and
process sensation from movement and the environment
and use it to plan and organize behavior
o 2. Individuals who have a decreased ability to process
sensation also may have difficulty producing appropriate
actions, which, in turn, may interfere with learning and
behavior
o 3. Enhanced sensation, as a part of meaningful activity
that yields an adaptive interaction, improves the ability to
process sensation, thereby enhancing learning and
behavior
(Ayres, 2005)

Relevance & Utility

Utility:
Adapt the childs environment in ways that will facilitate

the childs ability to successfully participate

Characteristics:
Modifications to the childs clothing
Altering room configurations
Noise or light levels
Experimenting with food textures
Adapting tools and materials
Changing program demands

Key Factors:
Increase functionality and sensory processing

capabilities vs. trying to change underlying neurological


functioning
(Ayres, 2005)

Sensory Integration

Why this theory?


The diagnosis of Lennox-Gastaut combined with Cerebral
Palsy often presents problems integrating sensory
information in combination with a motor disorder
Hindered ability to move against gravity, integrate primitive
reflexes, experience body exploration and experience
tactile, proprioceptive and vestibular inputs as typically
developing children do
Lacks specific types of play that yields tactile,
proprioceptive and vestibular inputs, limiting opportunities to
develop efficient, accurate sensory processing and
preventing quality sensory-motor experiences
Lack of movement prevents development of postural
reactions, postural control and good body scheme, the
foundation for motor planning and development of good
bilateral coordination

(Smith Roley, Blanche & Schaaf, 2001)

Evaluation

Observe how the child responds to:


Visual
Auditory
Touch
Taste
Movement
Multi sensory stimuli
Rating over- or under-responsiveness
to input

Sensory Profile

Purpose
Caregiver Questionnaire
Link the childs daily performance strengths
and barriers with specific sensory processing
patterns
Evaluate and determine the possible
contributions of sensory processing to daily
performance patterns
Provides information regarding both the childs
inclination to respond to stimuli, and which
sensory systems are most likely to contribute
or possibly create barriers for functional
performance
(Dunn & Ermer, 1998)

SIT Intervention Process


T

Sensory Integration Intervention


Approach Structure

Intervention
Implementation

The adaptive

response
Purposeful activity
Principles of motor
learning

Retrieved from
https://www.facebook.com/pages/EthansJourney/471216282932228

Adaptive behavior
influenced by sensory
environment
FM cause/effect toys to
incorporate grasp, accuracy,
concept formation

FM and grasp/prehension goals

Encouraging the child to


actively explore and problem
solve around complex goaldirected tasks in meaningful
environments; appropriate
verbal feedback;
generalization

(Levac, Wishart, Missiuna & Wright 2009)

SIT Intervention Process

Just Right Challenge

Incorporating proprioceptive-based and deep


pressure input within a ball pit setting
Facilitating HOH A for FM tasks with increased
participation secondary to sensory input

Retrieved from
http://www.yourbabysneeds.com/on11013.html

Retrieved from http://mindfulmovement.tumblr.com/page/2

Retrieved from
http://izaiahsscroll.blogspot.com/2013/07/3-new-tome-sensory-tricks-and-other.html

PEOP vs SIT

COMPARISONS &
OUTCOMES

Unique Theoretical Qualities


SIT

PEOP

Client-centered top down


approach
Occupational performance
targeted area of concern
Used across the lifespan
Compliments current global
concerns of health care-- well
being, health prevention
&promotion, quality of life &
social inclusion

(Baum & Christiansen, 2005)

The organization of sensation


from the body and the
environment for use, and the
ability to take in, sort out and
connect information from the
world around us
The ability to integrate sensory
information to evoke an adaptive
response
Motor learning is influenced by, if
not dependent on, incoming
sensation
The sensory systems develop in
an integrated
and
dependent
(Smith
Roley,
Blanche & Schaaf,

Outcomes

Family
Accomplish STG & LTG
Be as independent as possible in order to
participate in age-appropriate activities
HEP to incorporate sensory input to increase success
OT/parent collaboration
Physio Team
Reach maximal independence
Provide appropriate resources to family to increase
follow-through and success
Incorporate cost-effective strategies within HEP to
address sensory dysfunction at home and in community

Retrieved from http://code.tutsplus.com/tutorials

References

Ayres, A. J. (2005). Sensory integration and the child, 25th anniversary


edition. Los Angeles: Western Psychological Services.
Baum, C. M., & Christiansen, C. H. (2005). PersonEnvironment
OccupationPerformance: An occupation-based framework for
practice.
In C. Christiansen, C. M. Baum, & J. Bass-Haugen
(Eds.), Occupational
therapy: Performance, participation, and
well-being (pp. 242267).
Thorofare, NJ: Slack
Crumrine, P. K. (2002). Lennox-Gastaut syndrome. Journal of child
neurology,17(1 suppl), S70-S75.
Dunn, W., Ermer, J. (1998). The Sensory Profile: A Discriminant
Analysis
of Children With and Without Disabilities. The American
Journal of Occupational Therapy, Volume 52 (number 4), 283-290
Levac, D., Wishart, L., Missiuna, C., & Wright, V. (2009). The application
of motor learning strategies within functionally based interventions for
children with neuromotor conditions. Pediatric
Physical Therapy, 21(4),
345-355.
Smith Roley, S., Blanche, E., Schaaf, R., (2001). Understanding the
Nature of Sensory Integration with Diverse Populations. Therapy Skill
Builders.