Labyrinth Journeys

Saturday, January 27, 2007

Labyrinth Journeys

Friday, January 26, 2007

The Matter of Tone

Therapists providing intervention to children with movement challenges have traditionally considered and have perhaps treated "muscle tone" specifically as an impairment impeding motor performance in daily living function. In our hands, we can "feel" the resistance, heaviness, responsiveness and changes of each child's body with whom we interface in therapy. Our own motor system learns and remembers how each child's limbs and body feel in the various positions we place them in and during the movement experiences we provide them in therapy. We know in our hands how quickly the child is able to bring their muscles on line and how much help they need from our cues in order to be able to activate, hold or change the subtle movements in their bodies. We store this data in our own kinesthetic memory; the force production, the speed of movement and the directional cues provided through our motor system as we interact with a client's movement; we remember how that feels each session. It is like learning to dance with a partner, moving as one! The challenge of course lies in our capacity to measure and to accurately describe with words in a quantifiable and qualifiable ways indicating change in functional performance.

We also know from experience that changing the "feel" of the child's body does not always translate into an automatic change in movement performance. There are many motor control components that contribute to what we know as "action". Muscle activation, coordination, postural control and voluntary movement are all components of movement performance. In our practice, many of us see children with many different varieties of muscle tone occurring within a broad spectrum of possibilities. Floppy throughout their bodies, floppy in certain muscle groups, fluctuating in floppiness, stiffness, stiff in some muscles while floppy in other muscles and so on. We also know that the complex neural nets involved in producing tone or this state of readiness to move are influenced by a multitude of factors such as motivation, cognition, mood, arousal, hunger, illness, etc. further contributing to the complexity of this matter. As we influence this state of readiness to move with our intervention, we must consider the many other components of motor control.

Science has attempted to investigate this issue of tone as it contributes to motor control. To date we do not have an appropriate animal model that sufficiently mimics the tone changes we see in human neurological impairments. As a result, we don't yet have a complete understanding of how tone is generated in the neuro-musclar system.

Early on in motor control research, it was believed that the brain worked like a step ladder, with each subsequent step working properly for the next step to function. Now, we know that the brain works more like a factory with many parts of the brain working together simultaneously and synchronistically to produce a single action. Our brain is an eloquently designed structure, built for efficiency! Many systems and parts working together to create the whole. This means in therapy that our ability to discover exactly which part of the nervous system isn't working will be tricky! It also means that we have more than one road to the same end.

There are both neural and non-neural aspects involved in getting the body ready to move. Studies investigating the "neural part" of tone have examined muscle spindles or the sensory receptors located in the muscles that register stretch of muscle fibers. Continuous neural information from the brain seems to change the channel on the receptivity of the muscle spindle, increasing its reactivity to sensory input. A motor contraction is easily stimulated in the presence of small stretch stimulus. It remains unresolved to date whether this augemented drive of "tone" in spastic muscle is caused solely by an increase in excitation from the neural structures in the brain or whether there is a loss of inhibitory influences in the brain. Is it too much information or not enough inhibition? The jury is out.

In addition to the nervous system, we also have a musculoskeletal system that is affected by tone. This includes muscles, tendons, connective tissue and ligaments. We can examine muscles with ultrasound and with electromyography to determine how they are contracting and the timing of their activation. We can also do biopsies of muscle fibers and tissue to examine the cellular structure in different subjects with motor impairments. Studies conducted in the 1980's emphasized changes in muscle fibers, emphasizing changes in muscle fiber types in response to spastic neural drive. These studies indicated that muscle fibers converted in structure, adapting to the continuous neural messages sent from the brain to the motor units in muscles. It appeared that the constant "on" message to a muscle changed the muscle fiber's responsiveness to neural information. Muscles that were traditionally used for moving a limb, for example seemed to change in structure and function, altering the fiber's potential for movement to a fiber responsible for posture. Muscles designed to move become muscles designed to hold on against gravity. With increasing sophistication in technology, science is now discovering that this conversion of fiber typing is not consistently observed in neuromotor dysfunction. Tone changes do not equal muscle fiber changes.

What we are finding in current research however, is that spasticity does change the cellular structure of muscle fibers rather than just the phenotype of a muscle fiber. Changes in sarcomere stucture, intracellular proteins and extracellular matrix substance have been observed in muscles identified as spastic in nature. Changes in the amount of connective tissue and collagen types were also consistently noted in the spastic muscles. Increased connective tissue or collagen where muscle fibers should be would suggest a definite change in a muscles potential to do it's job properly!

Not only must we consider muscles that are stiff as problematic in motor performance, but also consider the challenges of children who are floppy or hypotonic. This floppy state of readiness to move is even more prevalent in children with neuro-motor challenges than the state of stiffness. Despite the frequency of a continuum of hypotonia, the etiology of this phenomenon is even less understood than hypertonia. Floppy tone is associated with a wide variety of pathophysiologies of the neurological, metabolic, genetic and musculoskeletal systems.

In children with hypotonia we typically observe a situation where musculoskeletal structures take on the role of maintaining the stability of posture against gravity; children will bend their joints into end range or lean into their joint surfaces, locking them in order to stay upright against the forces of gravity. These motor strategies help the child compensate for muscles that have a hard time "coming online". It may be difficult for these children to use their muscles appropriately in concert to produce a movement, either holding on too tightly or with insufficient strength to produce smooth and efficient movement patterns. This interaction between the brain and the body is an integrated dance of inter-communication.

Although we are not yet be able to scientifically understand or measure this phenomenon of "tone", we as therapists intuitively and functionally know that the state of readiness to move is a foundation for motor performance. Through sensory cues, environmental adaptations and the rehearsal of motor skills, this important substrate for movement continues to be both an implicit and an explicit aspect of our therapeutic intervention.

Sunday, April 02, 2006

Hope as a Healing Force

As therapists we are positioned to bring new ideas and possible solutions to families of children with special needs. Often the families we are there to serve experience a "state of desparation" and "hopelessness", floundering for ways to help their child. This state of vulnerability expressed by families can seemingly place us as professionals into potential positions of power over the family rather than in a mutual partnership.

Throughout my career as a therapist and teacher, I have faced many an accusation from my peers as offering "false hopes" to families through my enthusiasm and beliefs of human potential. The belief in the necessity to empower others through hopefulness and optimism is often misinterpreted as a misleading path of delusion that confuses and leaves families powerless.

This experience has intermittently resulting in my feeling daunted and saddened, left to explore the root of my reaction to these returning experiences. Why is it that so many find it necessary to champion "realism", squash inspiration and dispell "denial". What is the underlying fear experienced by so many? Why do we feel so responsible for the experiences of others?

What is hope?

Hope is defined as a "feeling of trust and a desire for good, it is accompanied by the assumption that the desire is attainable; requiring faith". That is a loaded definition!

The description "feeling of trust and desire for good" implies an honest intention. An authentic desire for a positive outcome. The word honest demands self-inquiry and examination on the part of the therapist. An examination into the dark corners of the self; aspects of the ego that may be hooked into the powerful feelings linked to the helping role. Honest also requires an investigation into one's personal beliefs about healing and the role we each play in this process.

In my experience of the healing process, healing and curing are often terms used interchangeably. The healing process being a movement from a state of dis-ease and discomfort towards ease. A process that does not always involve a cure.

Professionally, when we engage with a family in a therapeutic relationship it is necessary that we desire a positive outcome as an aspect of our intention, otherwise we would be of limited benefit to the situation. A positive outcome can be disguised in many forms, and may not always be apparent in the moment. One of my clients, who is now twenty years old recently reported that what he remembers most about his therapy sessions as a child was how good he felt about himself after the sessions and not the actual skills he learned at all!

As therapists we are in a position to support, encourage and empower families as they walk this path of healing. The ups, the downs, the flux, the dissapointments and the triumphs are all part of the journey we experience with clients. We are but a small piece of this process, with many other influences having impact upon each family's individual experience. The intimacy of the relationship we share with our clients provides us with the opportunity to be an observer of the process with suggestions and ideas that may support families in shifting their perceptions of their experience. This is transformation in the making.

Ultimately, it is the family that is responsible for their choices! The healing responsiblity is ultimately an individualized one and not a path that follows any pre-determined prescription. Perhaps we will play a part in the healing process of our clients and perhaps we will not. It is not a situation that requires judgment; merely observation.

The second part of the definition of hope involves the "assumption that the desire is attainable?" This is the aspect of the definition that requires faith. Each of us as therapists bring to the therapeutic process a set of ideals, beliefs and assumptions about the human capacity for healing, change and growth. This spiritual aspect of our practice is often implicit and hidden in the background. Our increasing pressure for accountability, sustainability and professionaliaty emphasizes that we prove efficacy in all that we do. This is a contradiction to the process of healing which requires a state of hope and optimism in the human spirit beyond what is proven.

Hope can be an idea of the mind, that when lacking the ignition of faith is "false hope". Hope can be a disguise for denial , but the continuum of hopefulness treads through phases of doubt and despair. We often aspire to be hopeful, but when change is not readily apparent in the healing outcome, we become discouraged. Without alignment between acceptance of what is and hopefulness for something more, hope merely becomes an intention rather than a true state of being.

Psycho-neuro-immuno-endocrinology, the science of mind body connection reminds us of the power of the state of mind over the physiology. When you are in a state of hopefulness, your cells are shining! Your immune system becomes primed for optimum state!

So how then can we create "false hopes"? Unless we are promising cures in our statements to families, best practice includes connection, inspiration and motivation to help clients learn and participate in the healing process.

Lastly, families who fall prey to "false hopes" and set off on a search for cures, are actively embarked upon the healing path. They are demonstrating to us clearly, where they are at in their healing experience. When we practice ethically, professionally and in good faith the intention of healing is in place. Inspiring hope with an authentic belief in human capactity, empowers others to believe in themselves as they experience the human journey.

Saturday, March 25, 2006

Explaining Sensory Regulation in Layman's Terms

Therapists frequently ask "How do I explain these concepts to parents?" "What is sensory regulation?"

In order to participate in our every day tasks we need a background of alertness that is created in the brain allowing us to attend, think and participate. Different tasks require different states of arousal and alertness. The state needed to watch tv is quite different from the one required for playing soccer!

The typical nervous system has the flexibility and skills to adapt and move from one state to another with ease. Many of the children we work with have greater difficulty with this ability. For some reason their brains do not have the ease of connection to alter, regulate and organize the internal chemistry of the brain or the behavior that we see.

With practice of the right type of experience, the brain can learn to REGULATE and organize itself. When there is a match between the just right state of the brain and the demands of the environment, the brain goes "AHA" and the neural nets line up. This is called state dependent learning.

The goal of therapy is to help find the "AHA" so that the child can learn to SELF-REGULATE and use thinking, sensation and the environmen t to learn to change their own behavioral state.
In my mind self-regulation is the substrate for all learning, interaction and functional performance.

Connection, Fear and Sensory Processing

This is a topic near and dear to my heart!

Studying the brain has taught me how intimately connected the sensory systems are to the emotional centers (limbic system) and the rational centers (frontal cortex) of the brain. The bucket of chemicals that lives inside the amygdala (amy for short) does not know the difference between the sensory terrifying experience of fluffies in the socks from an earthquake! Each experience is interpreted through the perception of the individual.

When our clients are sensory defensive, their experience of sensations produce a dramatic neurochemical reaction of fear in the brain that becomes "engramed" or hardwired as an experience to be avoided. This is the case no matter how silly the behavior appears.

Because our nervous systems are wired for survival, fear responses occur very quickly and often subconsciously without time for rational thought to override the chemical reaction. The autonomic nervous system is triggered into fight, flight or fright, before a neuron in the frontal cortex has even registered the idea that fluffies are silly! This is especially true for young children who have a less mature frontal cortex.

Once a fear response is hard wired, it is hard to "talk" the brain out of its response. A titrated bridge of comfort is needed that dialogues with the subconscious and lower levels of the brain feeding in information that soothes the activated "amy" fear response. Such bridges as deep pressure, heavy work, soft music, rhythm, comforting touch and therapeutic connection send messages to the brain in conjunction with the fear inducing stimulus concomittantly helping the system learn to regulate and organize in a new way. The bucket of chemicals diminishes in intensity and the client learns that fluffies aren't so bad.

Therapists often ask "How do I explain this to the client?" Validating the child's experience is essential "I know that you don't like the feeling of your socks" "It is scary for you". "Let's see what we can do to help your brain change how those socks feel." Connection, reassurance and a new plan are in place.

The combination of therapeutic use of self, attachment and just right stimulation are a blend of intervention to change the channel of the "amy" from fear to organization.

What does Hypotonia have to do with Austim?

This is another wonderful frequently asked question! As you know there are so many variations to the theme of ASD and so really we are lumping a group of children together who someday may be differentiated like apples and oranges. Motor control issues are a prevalent aspect of challenge for many children with austim spectrum disorder and increasing research is helping to validate these observations.

Researcher Philip Teitelbaum of the University of Florida, has researched early signs of autism in infants through investigation of their motor patterns. In 1998, Dr. Teitelbaum, evaluated 17 autistic children aged 4-6 months through videotape analysis. The videotapes were tapes of children made by parents long before they had been diagnosed with autism. The movement patterns of these infants were compared to patterns observed in 15 typical developing children. Every single child in the study who was later diagnosed with ASD demonstrated a motor disturbance!

Disturbances were revealed in the quality of their motor milestones; demonstrating difficulties in movements requiring rotation (turning over from lying to side), difficulties in maintaining trunk control in sitting, asymmetries of posture and floppy muscle tone!

Dr. Eric Courchesne, neurobiologist and colleagues have also performed extensive research using neuroimaging on the brain of clients with autism. These studies have emphasized a morphological differences in the cerebellum, exhibiting a cerebellum that is smaller in size and different in cellular configuration. Suggestion has been made that these alterations may in fact contribute to the subtle motor control challenges experienced by this distinct population of clients.

Teitelbaum, P., Teitelbaum, O., Nye, J., Fryman, J. & Maurer, R. (1998). Movement analysis in infancy may be useful for early diagnosis of autism. Psychology, 95: 23, 13982-13987.

Vestibular Stimulation and Seizures

The vestibular system helps us to understand the position of our head and body in gravity-bound space. It gives us information about which way is up and which direction we are going. It assists our body with balance, spatial orientation and maintaining a stable visual field, even when we are moving. Since movement is a part of everything that we do, the vestibular system is always working in the background.

Many children experience challenges in the processing of vestibular information. Some children seek out movement while others actively avoid movement experiences. Activities that assist the vestibualr system in learning balanced modualtion that contributes to daily function can be an integral component of a sensory processing program.

But what about children who experience seizures? This is a very common question asked by therapists. Typically, it is a moving visual array that can trigger seizure provocation and not necessarily the vestibular stimulation itself. Thereby, swinging, spinning and fast movement can create problems in that naturally the world is moving in relationship to the body. Rotation seems to be the greatest stressor on the nervous system and should not be used with clients who have known photic-evoked seizures, unless all of the light can be kept from the eyes. Children who seizure but do not experience a photic component to their profile can have controlled vestibular input introduced into their experience, but in a graded and slow manner that allows the therapist to carefully observe the child's reaction. Watch carefully for signs of sensory overload. These signs can occur even with the best observation and clinical reasoning. Examples of behaviors that signify overload are: yawning, changes in skin color, headache, changes in heart rate or respiration, pupil dialation, prolonged dizziness or nausea. Remember that vestibular stimulation is cumulative and that a reaction to the input provided during therapy can occur later outside of the session.

Offset over-stimulation with immediate vigorous, intensive, proprioceptive input. Such activities as
  • Running, crawling or jumping vigorously around the room.
  • Have the child place their hands on their head and press down while jumping in place. Combine with sucking vigorsously with lips sealed.
  • Place ice cubes into the client's hands, at the base of skull and on the temples.
  • Have the child push into a crash matt or wall with their entire body as hard as they can.
  • Postion the child in prone on forearms and have them blow vigorously with resistance.
These activities are modulating in effect!

When in doubt discuss the use of vestibular stimulation with the child's physician!

Friday, March 03, 2006

Becoming A Detective

The tricky part about "reading" your patient's nervous system and their sensory needs is that this process keeps you on your toes! The difficulty with sensory diets or "programs' is that they don't always allow you to "read" the nervous system of the child in the moment. Questions like "what is the child's current state?" before you begin a sensory intervention is key in deciding which types of activities might be helpful in moving the child's state towards homeostasis. Too often when following prescribed activities, flexibility is limited in meeting the childs CHANGING needs.

Many children with autism experience fluctuations in their sensory processing. This means that their sensory needs are in flux. The effective sensory strategy on one day, can bomb completely on another day. "Being present" to the child's current state helps the therapist decide in that moment where the child may be in their overall state of arousal. Are they hypo? hyper? or over-stimulated? Remember that when children are over-stimulated, they often pass through a hyper arousal state (giggling, laughing, flushing, etc) on their way to an organized state. Perhaps calming activity needs to be continued for a longer period of time as the child passes through the hyper-aroused state transiently.

Children with autism may have a wide variety of sensory processing issues. They may have difficulty with the initial "registration" of a sensation; where the brain is unable to "notice" the feeling of that sensation. At times there is a delay in processing time of a sensation, where there is a 'kick back" or a long duration for the brain to notice the sensation. Often we continue providing a sensory experience beyond the duration necessary as we perceiving the child's sensory threshold to be high; whereas in reality, the threshold may be low, and have a long latency in time for detection. The three variables we can play with when providing an experience are frequency, intensity and duration of a sensory stimulus. How often do we provide an experience? For how long? and to what intensity? Sensory intervention is not as simple as providing a regime of sensory feedback!

Sometimes children with sensory processing challenges become excited when they are actually connected to themselves! The excitement or increased arousal that we observe may be about feeling present and in their body. This is an increase in emotional arousal resulting from experience rather than an arousal created by too much sensory feedback. Discerning this situation requires an especially fine magnifying glass. Children who seek to repeat and repeat and repeat an activity often are emotionally charged by the successful processing of the experience. "I like this feeling!"

One other situation that deserves consideration is that sometimes many different sensory interventions need to be combined together in order to "ground" the nervous system. For example, many children need to combine listening intervention with movement, deep pressure touch, heavy work and purposeful task in order for the sensation to "have meaning". Raw sensory data can "bounce around in the nervous system" without grounding or organizing the child's overall behavior. One stimulus at a time may not be sufficient to be organizing.

As ususal, one question leads to another like a road map or pieces of a puzzle. The nervous system of children with sensory processing challenges creates a wonderful opportunity to become a detective!

Friday, February 17, 2006

What is Addiction?

When differentiating between "physical" addiction and "psychological" addiction in newborns of addicted mom's, it is a slippery slope of distinction. It is known that physical addiction comes about through an array of neuroadaptive changes and the laying down and strengthening of new memory connections in various circuits in the brain. We do not yet know all the relevant mechanisms, but the evidence suggests that it is the long-lasting brain changes from prolonged drug use that are responsible for the distortions of cognitve and emotional functioning that characterize addictive behaviors, possibly including the cravings of psychological addiction.

Scientists are characterizing physical addiction as a circumstance occuring when a person's body becomes dependent on a particular substance and that this person builds tolerance to that substance, so that the person needs a larger dose than previous to achieve the same effect. Psychological addiction is characterized by the scientific community as the cravings or desire involved in needing the chemical. One form of addiction is neurochemical, while the other is a perceptual experience of needing the substance.

It is hypothesized by the medical community that the baby's brain has not had a long enough period of exposure to become actually addicted or physically dependent on the drug beyond the withdrawl period. This distinction does not mean that the baby has not experienced a neuroadaptive response in utero and possible permanent nervous system damage as a response to the drug. It simply means that we can not confidently state that a baby is neurochemically "addicted" as we define addiction in the adult population.

On the other hand, babies definitely experience withdrawl from drugs as is described as Neonatal Abstinence Syndrome. It is speculated that based upon what we know about "learning", the baby has learned how it feels to be influenced by the drug and perceives the absence of it.

I hope this helps to define and clarify the concept of neonatal addiction. This blog continues to welcome both questions and also additional information that may serve to clarify or expand concepts discussed here....Kim

Friday, February 10, 2006

Neonatal Abstinence Syndrome

A large number of drugs pass from the mothers' blood stream through the placenta to the fetus. Drugs of abuse have a low molecular weight and lipid solubility making it easier to cross the placenta. When drugs or other substances of abuse are taken by the mother equilibrium is established between the materanal and fetal circulations. This in utero equilibrium provides a constant supply to the baby and with the mothers' excretory and metabolic mechanisms the drug is cleared from the baby's circulation. During this time, the fetus undergoes a biochemical adaptation to the abnormal in utero environment and as a result the addiction of the mother now becomes the psychological addiction of the fetus. The substance exposed baby is NOT actually addicted, instead it is the psychological cravings that lead to substance seeking behaviors.

The baby's dependence on the substance continues after birth and with the cutting of the cord the baby's drug supply is abruptly removed. The baby however continues to metabolize and excrete the substance and when low tissue levels have been reached withdrawl signs occur. Since the drug is no longer available the baby's central nervous system becomes overstimulated causing the symptoms of withdrawl.

There are two theories on neonatal withdrawl

1. Disuse hypersensitivity theory where the nervous system responds to the depressant drug
by increasing the sensitivity of the target receptors in the brain. The removal of the drug
causes the target receptors to become overwhelmed by input that was previously blocked
by the drug.

2. Neural hyperactivity theory occurs when normal minor activity pathways become more
active when the depressant drug blocks the usual neural pathway. When the depressant
drug is removed, both pathways are active resulting in neural hyperactivity.

Withdrawl symptoms occur from a few hours up to 2 weeks of age. The timing of the withdrawl onset depends on the time of the last drug exposure and the metabolism and excretion of the drug and its metabolites.

The behaviors we see in infants are:
  • high pitched cry
  • inability to sleep
  • frantic sucking of fists
  • yawning
  • sneezing
  • nasal stuffiness
  • poor feeding behaviors
  • regurgitation, vomiting and losse stools
  • hyperactive moro reflex
  • hypertonicity
  • tremors

What can we do?

  • swaddling (deep pressure touch)
  • soft pack baby carrier
  • smooth slow rocking
  • pacifier
  • decrease feeding intervals
  • reduce environmental stimuli
  • lambskin bedding

Although no actual studies have been found to date identifying long term changes to the receptor sites within the nervous system, many therapists report long term sensory processing challenges and arousal issues in this population. What have you observed?