Vol. 25 • Issue 23 • Page 22
What happens when a client with sensory processing issues also has other needs? What if that client has motor, visual, auditory or cognitive limitations as well?
Sensory processing disorder (SPD) may not be readily apparent in a client who has other significant diagnoses. Standard evaluation tools may not be practical or accurate due to limited motor, cognitive or visual skills. It may take more effort and different strategies to determine if the client is seeking certain stimuli or is being over-stimulated by other stimuli.
Standard therapeutic interventions may not be possible either. For example, if a sensory diet is recommended, modifications may be required to provide the client independence in selecting a sensory activity and regulating the intensity and duration of the activity.
This is where assistive technology and sensory processing can overlap. Assistive technology may provide an alternative means of accessing a sensory diet for clients who have motor, cognitive or visual limitations in addition to sensory processing issues.
Vestibular stimulation is traditionally provided through swinging. If a client cannot use typical therapy swings,
adaptive swings are available for those who require more postural support. Some swings are designed to support an entire wheelchair, so the client can stay in his seating system. If a motor was available, the client might be able to use a switch to control the duration of movement; however, I have been unable to find a motorized swing for anyone larger than an infant.
Movement provides vestibular input. Any form of movement can be helpful, including adaptive bikes, gait trainers, walkers and manual and power wheelchairs. Dynamic seating provides for movement within the seating system of the wheelchair. Movement can also be provided by actuators on wheelchairs, such as a tilt or recline option. If these are powered, the client can independently choose when they want to change their position in space and how much.
Proprioceptive input is often provided by weighted vests or by having a client push or pull on heavy items. Clients seated in wheelchairs often can use weighted vests. Wrist and ankle weights may not have the same benefit for a client who is not ambulatory or using his arms for functional tasks. I have had some success using TheraTogs to provide proprioceptive input as well as additional postural support and stability for children in fitted wheelchair seating systems. The TheraTogs are very thin and fit more easily within the seating system.
Mobility devices may provide joint compression and proprioceptive input. Moving with a gait trainer or walker or propelling a manual wheelchair all require motor work that can provide important and needed sensory input for clients who are seeking this stimulation.
Occupational therapy practitioners are very good at coming up with tactile experiences for their clients. Those with limited fine-motor skills still can use gross-motor patterns to move through a large container of rice or pudding.
Another tactile option that can be adapted for alternative access is vibration. Several manufacturers offer battery-operated vibrating devices that are switch adapted; those that are electrical can be plugged into a device such as the Ablenet PowerLink to provide intermittent switch control.
Vibration can become noxious quickly, so it is very important that the client be able to turn this off independently.
Visual and Auditory
A host of battery-operated and electrical devices provide mild to significant visual and auditory stimulation. One company that offers many options that provide visual, auditory and/or tactile stimulation is Enabling Devices (www.enablingdevices.com). Many of these are designed to be accessed by clients with motor and sensory limitations.
Tom has motor and visual limitations; tactile and auditory input calm him.
Tom is a 40-year-old man with the diagnoses of cerebral palsy, cognitive impairments and blindness. He is non-ambulatory, though he has limited self-propulsion skills with his manual wheelchair. He is non-verbal and has been unsuccessful in using a speech-generating device in the past.
Tom was referred to me to explore assistive technology options to help with his behavior. This is not my typical referral. I visited Tom at his group home and spoke with his caregivers. He often yelled and pounded the table during the day, appearing to be agitated. The staff believed increasing his control over his environment might lessen his agitation.
Tom's activity of choice was pulling pieces of material out of a bucket and feeling the various textures. He also enjoyed auditory input. We tried other various items to determine other activities Tom might enjoy.
We put a long table against a wall in the common area and set up Tom's preferred activities in consistent locations along the table so that he could find them despite his visual limitations. Tom was able to propel his manual wheelchair to this table and "explore" each of these activities:
• his bucket of materials of various textures. He could independently access these whenever he chose;
• a vibrating switch. When he pressed this with his hands or cheek, the surface vibrated;
• headphones that he was able to independently place on his ears. When he pressed a switch (connected to a cassette player via an Ablenet PowerLink), music would play for a pre-programmed amount of time; and
• a multisensory station from Enabling Devices that included various auditory and tactile experiences, including a radio, a fan, a buzzer and a vibrating plate. Each was activated by switches or large, easy-to-press buttons.
Brady has motor and visual limitations; he seeks oral input, while proprioceptive input calms him.
Brady is a 10-year-old boy with diagnoses of cerebral palsy and cortical visual impairment. He is non-verbal but uses his speech-generating device very well. He is non-ambulatory and is unable to use a power wheelchair at this time due to lack of motor control.
I had already been working with Brady on positioning and access needs when I noted quite a bit of tremoring in his upper extremities and head. Deep pressure and joint compression not only reduced his tremoring, but he calmed in general and indicated that he liked this input.
Brady uses a custom-molded seating system, and a weighted vest would not fit in this intimate system. We tried Thera-Togs to provide proprioceptive input to his trunk. Brady reported that this helped him to feel calmer, and his tremoring often appeared reduced. These thin garments did not affect the fit of the molded seating system.
Brady's parents already knew that he craved oral input. Brady is tube fed as he does not have a safe swallow. He enjoys chewing on stretchy tubing and firm surfaces. He is unable to pick these up and hold them in his mouth due to his motor limitations. We programmed his speech-generating device so that he could ask his parents or the school staff to bring him his choice of an oral chew device and hold it in his mouth for him.
Technology could provide independence in this task; a motorized swing-away mount triggered by switch input is available. It is designed to move a sip-and-puff control for a power wheelchair in front of a client's mouth. We could use this device to move tubing in front of Brady's mouth for him to chew on, as desired. However, it is costly, and his funding source will not pay for this option.
Alexi has motor limitations; he seeks vestibular input, and auditory input calms him.
Alexi, 18, has a diagnosis of traumatic brain injury. When I first met Alexi, he was extremely agitated and the only thing that calmed him down was certain music. He became agitated when we attempted to work on positioning and access to a speech-generating device.
In order to get started with Alexi, we plugged a cassette player into an Ablenet PowerLink and inserted his favorite music. When he became upset, we turned the music on to calm him down.
We slowly moved the switch over to his control. He began to realize that when he hit the switch, he was turning on the music independently.
When he realized he had this control, we were able to transfer these skills to a speech-generating device (SGD). His initial choices on the SGD were the titles of two of his favorite music cassettes.
Several years later, Alexi is able to accurately navigate between a number of pages of vocabulary choices. Some of his vocabulary still provides him sensory choices such as music. He can also use his SGD to send an infrared signal to a stereo system to turn on music independently.
Alexi loves movement. He is very motivated to move his body and becomes very frustrated if he cannot move.
He uses a gait trainer with assistance.
This does not provide very functional mobility for him, but does provide weight bearing, lower-extremity strengthening and movement.
He has been fairly resistant to his manual wheelchair, although he is positioned well and can access his assistive technology from this position.
Alexi recently tried a KidsRock manual wheelchair (Sunrise Medical, ART Group). This chair is dynamic, and the seat-to-back and knee angles open when the client extends his body. Springs allow this movement and help the client return to his starting point. Alexi is able to move in his seating system and yet not
lose his position or ability to access his technology. This ability to move has prolonged his seating tolerance and has reduced his agitation.
Eric has mobility limitations; proprioceptive and auditory input calm him.
Eric is 16, with cerebral palsy and anxiety disorder. He is verbal; however, when he is agitated he has a very difficult time expressing himself and becomes distressed and even aggressive.
During therapy, while he was feeling calm, Eric and I problem-solved a number of calming strategies for him. We made a picture of each, placed these on a piece of paper and laminated it.
When Eric became agitated, he could ask for this calming-strategies sheet or a caregiver would offer it to him. He would point to the option that he felt would be most helpful and his caregivers would then assist him.
"Rub my shoulders." Deep pressure calmed Eric.
"Let's talk about it." Just knowing that someone would sit down and give him their undivided attention while he tried to express himself was very helpful.
"I need some alone time." Sometimes the environment would get too crazy and he could indicate that he needed to go to a quiet area to calm down.
"Music." He would put on headphones (with assistance) and listen to his iPod, blocking out extraneous noise and listening to music that calmed him.
"I need a drink." Just taking a few sips of water calmed him. I believe this is a combination of oral input, which he does crave, and an activity to distract him from the anxiety.
The clients with whom I work need assistive technology to help them be as functional as possible despite significant physical, cognitive and sensory limitations. Providing a means for clients to regulate their sensory input as independently as possible is critical and has occupational therapy written all over it.
Michelle L. Lange, OTR, ABDA, ATP, is owner of Access to Independence in Arvada, CO. She can be reached at MichelleLange@msn.com or visit her Web site at www.atilange.com.