SAISI WEBSITE: Newsletter Vol...2 Volume 24 | No 1 | 2014 SAISI WEBSITE: Views contained in articles...

2 Volume 24 | No 1 | 2014SAISI WEBSITE: www.instsi.co.za Views contained in articles appearing in this newsletter do not necessarily reflect the opinion of the South African Institute for Sensory Integration.

ADDRESS TEL WORK TEL HOME FAX EMAIL EDITOR Rosa-Marié Olivier P.O. Box 17369 (011) 867 0015 (011) 867 0015 (011) 867 0015 [email protected] Randhart 1457SAISI EXECUTIVE COMMITTEE CHAIRPERSON Ray Anne Cook 9 Wonderboom St (021) 975 6609 (021) 976 2258 (021) 976 2258 [email protected] Eversdal Heights Durbanville 7550 VICE CHAIRPERSON Riëtte Smit P.O. Box 668 083 3000 951 083 3000 951 riette.smit@kznatal Bethlehem, 9700 SECRETARY Ninette Visser P.O. Box 461 (011) 475 1449 086 697 6697 [email protected] Strubensvalley 1735 TREASURER Marica Botha P.O. Box 10536 082 335 6386 082 335 6386 [email protected] Aston Manor 1630 HEAD OF EDCOM Janine van der Linde P.O. Box 2559 (011) 7173272 (011) 615 6900 [email protected] Potchefstroom 2520 SAISI BOARD MEMBERS Emmerentia Aldrich 27 James Scott St (051) 444 1026 (051) 444 1026 (051) 522 9286 [email protected] Westdene, Bloemfontein 9301 Stefanie Kruger P.O. Box 60750 (012) 667 3998 [email protected] Pierre v Ryneveld 0045 Sally Mackenzie 51 Wilson Street (044) 384 1536 (044) 384 1536 (044) 384 1536 [email protected] Hunters Home Knysna 6571 Annamarie van Jaarsveld P.O. Box 43218 (051) 401 2829 (051) 451 1782 (051) 401 3288 [email protected] Heuwelsig 9332 Corina Botha P.O. Box 32472 051 404 8942 (051) 522 5506 0867291476 [email protected] Fichardtpark 9317 Mari Greyling P.O.Box 25346 082 854 3382 (012) 460 2029 [email protected] Monument Park Pretoria 0105 Magdaleen Stadler P.O. Box 7131 (041) 379 3318 083 328 1715 [email protected] Newton Park Port Elizabeth 6055 Dana Katz P.O. Box 321 082 491 0314 082 491 0314 (021) 686 4264 [email protected] Bergvliet 7856 Celette Crafford 24 Dawn Close (021) 975 6609 (021) 975 0286 [email protected] Eversdal 7550Gina Rencken 3 Sanderstead (031) 260 7052 (031) 705 4784 [email protected] 97 Sander Rd, New Germany, KZN 3610Anneke Kruger P.O. Box 12637 083 447 5477 [email protected] Die Hoewes Pretoria 0163 Elze Pelser 3 Rietjie St (051) 432 4024 (051) 422 4197 [email protected] Pellissier, Bloemfontein 9301Amy Rode 21 Rokewood Ave 082 562 4147 (021) 887 9935 [email protected] Die Boord Stellenbosch 7600Nika Oberholster P.O. Box 539 082 372 7689 [email protected] Jeffreys Bay 6330 CO-OPTED MEMBERS Elna Jooste P.O. Box 349 (011) 954 3626 (011) 954 3626 086 689 7747 [email protected] Paardekraal 1752 SAISI OFFICE Aletta Kietzman P.O. Box 14510 (012) 362 5457 086 651 5438 [email protected] Hatfield 0028 ADVISORY BOARD MEMBERS Prof André Venter P.O. Box 29864 (051) 405 3181 [email protected] Danhof 9310 Dr Lorna Jacklin P.O. Box 269 (011) 481 5192 Glenvista 2058 Dr Jackie Visser P.O. Box 29962 (051) 410 4000 083 263 7199 [email protected] Danhof 9310 Marguerite Monvoisin 33 Saffraan St 082 870 7213 [email protected] Loevenstein Bellville 7530 Suzanne Smith-Roley 15 Songbird Lane (949) 581-1380 (949) 581-1384 [email protected] Aliso Viejo California 92656

SAISI Newsletter Vol 24 no 1 2014.indd 1 2014/03/05 1:04 PM

PORTFOLIOMANAGERS

CONTENTSSAISI NEWSLETTER VOLUME 24 NO 1 2014

4 Editorial Letter

5 Notice Board

6 Liaison News

7 The Vestibular Bilateral Integration Pattern:

A Unique Contribution to Sensory

Integration Theory and Practice

13 Bilateral Integration and Sequencing

Dysfunction: Strategies for Clinical

Reasoning

25 Activity Ideas

30 Book Review

31 CPD Programme Questionnaire

Volume 24 | No 1 | 2014 3

SAISI BOARD

EXCORay Anne Cook Chairperson

Riëtte Smit Vice Chairperson

Ninette Visser Secretary

Marica Botha Treasurer

Janine van der Linde Head of Edcom

Magdaleen Stadler Head of Liaisons

LIAISONSAnneke Kruger Gauteng

Elze Pelser Free State & Northern Cape

Celette Crafford Western Cape

Magdaleen Stadler Eastern Cape

Sally Mackenzie Southern Cape

Gina Rencken KwaZulu Natal

Annamarie van Jaarsveld International Liaison

EDCOMEmmerentia Aldrich Course Facilitator

Stefanie Kruger Theory

Rosa-Marié Olivier SIPT & Clinical Observations

Riëtte Smit Interpretation

Janine van der Linde Protocols

Sally Mackenzie Treatment

Corina Botha Diverse Populations

Marié Greyling Additional Core Courses

OTHERDana Katz Marketing & Ethics

Corina Botha Website

Annamarie van Jaarsveld Universities & Research

Ninette Visser CPD

Rosa-Marié Olivier Newsletter

Amy Rode Website Public Domain

& Newsletter Support

Nika Oberholster Standing Orders, Job Descriptions

& Newsletter Support

Riëtte Smit Policies

Magdaleen Stander SAQA

CO-OPTED MEMBERElna Jooste

ADVERTISING COSTSPRIVATE

3-4 sentences R 360.00

A5 R 496.00

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SAISI MEMBERS

3-4 sentences R 225.00

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CLOSING DATE

Closing date for contributions to

Newsletter vol 24 no 2 2014 is 23 June 2014.

bilateral integration & sequencing


4 Volume 24 | No 1 | 2014

Editor’s Letter

2014 HAS STARTED WITH A “BANG”

... riding on the good momentum from last year. The promised electronic version of the Newsletter is imminent! The whole new face of SAISI in the form of an updated, interactive and cutting-edge website will be launched at the AGM in May this year.

This newsletter continues with the theme of “Back to Basics” and the SIPT diagnostic group of Bilateral Integration & Sequencing gets some well-deserved attention. The latest research, some still in print, is revealed! I trust you will find this letter informative and encouraging.

Thank you for the feedback on the SAISI Newsletter. We have taken your suggestions to heart and will co-ordinate as rhythmically and sequentially as we can.

“Nobody cares how much you know, until they know how much you care.”

– Theodore Roosevelt

AmyCo-editor


Volume 24 | No 1 | 2014 5

Notice Board

WEBSITESAISI’s exciting new website will be launched at the AGM in the Western Cape in May!

PROTOCOLSRecord numbers of protocols have been received and SAISI is proud of its hard working members! Holding thumbs for great pass rates!

AGMSAISI is looking forward to another exciting AGM to be held in the Western Cape on 9 May. Venue and topics to be confirmed. Watch your emails for detailed information coming soon. Hope to see you there!

OT WhatsApp conversation:

Printed with permission from South East Rand OT’s.

“homework kills trees, stop this madness”


6 Volume 24 | No 1 | 2014

Liaison News

We had a busy and exciting 2013. Our SAISI interest group was well attended by between 10 and 14 OTs. Our meetings were held mostly on Friday mornings from 8h30 to 11h30. We try to organize at least one meeting per term. 2013 was the year to find out more about other therapies

that OT’s use in conjunction with SI. The following topics

were covered that led to very interesting discussions.

Elrie Maree (Occupational Therapist) gave a very

informative talk about Cranio-Sacral therapy as well as

neurological processes involved. Madri Hammond (OT)

gave a presentation about the Tomatis So-Listen therapy.

Kath Megaw (paediatric dietician from Cape Town) gave

a talk about inborn errors of metabolism and later the

year on different diets ( GAPS, KETOGENIC, gluten free)

for different diagnosis e.g. , gut related, ADHD, Autism,

epilepsy, brain tumors, etc.)

Ray Anne Cook presented her talk on ADHD and SI as

well as the update of the SIPT. Unfortunately this was

poorly attended by the OT’s. The OT’s who attended,

enjoyed her presentation. One OT’s feedback was that Ray

Anne must move more! Competition for Ray Anne!

A parent/ teacher evening about the lifespan of ADHD that

Ray Anne presented, was also organized by the liason.

This was well attended (91 parent/teachers). Ray Anne did

a great job as usual and the feedback was that she must

come and do a follow-up in 2014.

Eastern Cape SAISI Interest Group 2013


Volume 24 | No 1 | 2014 7

INTRODUCTIONDr. A. Jean Ayres first became interested in the role of the

vestibular system when she was completing post-doctoral

work at the Brain Research Institute at the University of

California at Los Angeles. Having worked with patients

who had frank neurological disorders such as cerebral

palsy and head injuries (Ayres, 1954, 1955a, 1955b,

1957), she was intrigued by the role that the tactile,

proprioceptive and vestibular sensory systems played

in learning, attention and behavior, as well as in social,

emotional, academic and skill development. During this

period in the 1960s, Ayres began to include a set of

measures in her early factor analytic studies that were

related to postural mechanisms, balance, ocular control

and laterality, as well as midline and bilateral integration

(Ayres, 1964, 1965, 1966a, 1966b, 1969). A grouping

of scores was consistently seen, which Ayres called

Disorders in Postural Bilateral Integration, and which she

described as:

“...poorly integrated primitive postural reflexes, immature equilibrium reactions, poor ocular control and deficits in a variety of subtle parameters that are related to the fact that man is a bilateral and symmetrical being. The lack of integration of function of the two sides of the body distinguishes this syndrome. “

(Ayres, 1972b, p.134)

During the 1970’s Ayres began to study the role of the

vestibular system more extensively and, in 1975 published

the Southern California Post Rotary Nystagmus Test

(Ayres, 1975) which allowed her to begin to include this

measure of central processing of vestibular input in her

research. She hypothesized that too little or “depressed”

post rotary nystagmus (PRN) reflected inefficient

processing of vestibular input in the vestibular nuclei of the

brainstem, while too much or “prolonged” PRN reflected

a problem in the typical inhibitory influences from other

neural centers, on this reflex.

In 1979, Ayres revised her description of Postural and

Bilateral Integration Deficit to Vestibular and Bilateral

Integration Deficit. She stated that,

“The symptoms of a vestibular-bilateral disorder are very subtle. These children are often considered completely normal until they enter school and have trouble with reading, arithmetic or other academic work...”

(Ayres, 1979, p. 79)

and she then proceeded to identify the following

Article

A Unique Contribution to Sensory Integration Theory & Practice

By Zoe Mailloux, OTD, OTR/L, FAOTA

THE VESTIBULAR BILATERAL INTEGRATION PATTERN:


Article

8 Volume 24 | No 1 | 2014

problems commonly associated with VBI disorder as:

poor eye muscle and postural responses; poor right-left

discrimination; delayed development of laterality and or

trouble crossing the midline, poor spatial orientation and

directionality, trouble with rhythm and bilateral actions and

a tendency to enjoy and seek movement activities without

typical signs of dizziness (Ayres, 1972d, 1979).

During this same period, in addition to conducting

research aimed at further clarification of patterns of

sensory integrative function and dysfunction, Ayres was

also examining the efficacy of the intervention methods

she had developed. In 1972, she published a paper

entitled Improving Academic Scores through Sensory

Integration in which she reported that a group of children

with learning disorders who received occupational therapy

using a sensory integration approach, five days a week

(25-40 minutes a day) for 5-6 months showed significantly

improved scores on the Wide Range Achievement Test

(WRAT) and on the Slosson Oral Reading Test (SORT) in

comparison to a matched group of children who received

equal time of classroom instruction (Ayres, 1972a).

While further studying the variables that would predict

positive educational outcomes, she published a paper

showing that duration of PRN was the best predictor of

change of reading and spelling scores with children who

had -1.1 SD or lower of PRN making greater gains that

those without shortened duration PRN (Ayres, 1978).

This study reflected her increasing understanding of the

role of the vestibular system and its role in academic

performance. In SI and the Child Ayres (1979) states,

“A number of studies in this country, in Australia, and in South America have shown that at least 50 percent of all children with learning or language problems have too short a duration of PRN. These findings suggest that some aspect of vestibular function is very important in meeting the demands of school-work, and this aspect is not functioning adequately in many school children today.” p. 72

This statement likely holds true even many decades later.

The Sensory Integration & Praxis TestsIn January 1989, the Sensory Integration and Praxis Tests

(SIPT) were published, one month after A. Jean Ayres

passed away following her battle with cancer. By the time

she was completing her work on the SIPT, her research

and clinical experience had reinforced that both depressed

and prolonged PRN were commonly seen in children with

learning and other developmental disorders. However, it

was also clear that these findings reflected different types

of sensory integrative problems. Because both high and

low PRN scores often existed in clinical populations, mean

PRN scores often “averaged” and appeared similar to the

mean scores of typically developing children. Therefore,

the SCPNT score did not load with other measures of

vestibular, postural and bilateral functions in the studies

through the 1970s and 1980s.

By the time Ayres had decided to revise the SCSIT

and SCPNT into the SIPT, she was keenly aware of

the increased standards in biostatistics. She hoped to

avoid the criticism of her work that would be likely should

she continue to include non-standardized measures of

vestibular-related postural and ocular mechanisms (e.g.

assumption of a prone extension position, eye tracking,

etc.) similar to the ones that she had previously used in

her studies. Instead, she relied solely on the carefully

designed tests of the SIPT, with their highly discriminative

items. The factor analyses that were conducted as part

of the development of the SIPT revealed a pattern that

was similar to the previously identified Vestibular Bilateral

Integration Disorder. However, without the presence of the

postural/ocular observation and with PRN not loading on

this pattern (most likely due to the issue of both low and

high PRN being present in the sample), she hesitated to

highlight the hypothesized vestibular nature of this pattern.

With several of the new tests loading on this pattern having

both a sequential element, as well as bilateral features,

(e.g. Sequencing Praxis, Oral Praxis and Manual Form

Perception), Ayres called this pattern Bilateral Integration

and Sequencing Deficit. In a discussion of bilateral

integration deficits in the SIPT manual, Ayres notes that

her clinical experience had suggested that short duration

of PRN was often associated with the BIS pattern

(Ayres, 1989).


Volume 24 | No 1 | 2014 9

For the factor analyses that Ayres conducted with data

from the SIPT, she examined the loadings in a variety

of samples in order to select patterns that were seen

consistently. Some patterns, such as Visuopraxis and

Somatorpraxis emerged in both samples of typically

developing children, as well as in mixed samples and

samples of only children with identified difficulties.

This finding led Ayres to hypothesize that visual and visual

practic functions, as well as tactile and somatopractic

functions were associated in typical development as well

as in patterns of dysfunction. She also noted, however, that

the linking of tests measuring bilateral integration, balance

and sequencing formed a pattern that was only evident in

a sample of children with identified difficulties. Therefore,

she did not believe that vestibular based inefficiencies

that were hypothesized to underlie the PBI, VBI and

BIS pattern would be present in any stage of typical

development.

The presentation of the BIS pattern in Sensory Integration

Theory and Practice (Fisher, & Murray, 1991; Bundy &

Murray, Lane 2002) as a milder form of dyspraxia led to

some debate among experts in sensory integration, as

well as some confusion for clinicians. Ayres considered

the various iteration of the bilateral integration pattern

(first Postural Bilateral Integration (PBI), then Vestibular

Bilateral Integration (VBI) and finally Bilateral Integration

and Sequencing (BIS) reflective of a pattern of sensory

integrative dysfunction that was characterized by the

discreet vestibular based signs with the absence of more

significant tactile or praxis deficits seen in patterns such

as Somatodyspraxia. Mulligan found similar loadings of

bilateral and sequencing tests, without associations with

the core tactile and praxis tests in her subsequent research

(1998; 2000).

Current ResearchWith many decades of research demonstrating consistent

patterns of sensory integrative function and dysfunction,

the need for continued study of these groupings was not

evident. However, Davies and Tucker (2010), in a review

of types of sensory integrative problems chose to restrict

their analysis to papers published in 1998 or later.

This choice led to exclusion of all of Ayres’ research on

sensory integrative patterns. At the same time, there was

continued interest in managing the issue of the existence

of both depressed and prolonged PRN in samples.

In 2011, we published a study involving retrospective

chart review and analysis of 273 children, aged 4 to 9

years (Mailloux, et al., 2011). The sample in this study

consisted mostly of children who came for evaluation at

private practices and had not been identified through usual

medical or educational diagnostic routes. In fact, most

subjects in the sample (N=214, 78.4%) had no diagnosis

on file. While methods for statistically managing both high

and low PRN were being explored, it was noted that very

few subjects in this sample had high or prolonged PRN

(23 subjects or 8.4%). The lack of many children with

prolonged PRN resulted in a range of scores on this test

that was more similar to the other tests (i.e. average or

low scores but few high scores in a sample of children

with probable sensory integrative concerns). The patterns

that were found in this study did, in fact, include a similar

pattern to the BIS pattern found by Ayres (1989) and

Mulligan (1998) but with the added loading of the PRN

test. In addition, the Motor Accuracy Test also had a

significant loading on this pattern, hypothesized to reflect

the coordination of eye-head and hand movements, as

well as the ability to cross the body midline. We called this

pattern Vestibular Bilateral Integration and Sequencing

(VBIS). Thus, these findings reinforced a long-held view of

the significance of low PRN scores and validated Ayres’

(1989) theoretical assumption that bilateral integration

problems and other signs of vestibular inefficiencies are

associated with a shortened duration of PRN.

More recently, other studies have examined the use of

the PRN test, as well as further consideration of the

Vestibular Bilateral Integration and Sequencing pattern.

Consideration of the possibility that the PRN test might

be applied with children younger than the current norms

which start at four years, was spurred by the observation

that the age trend on this test (reported in the SIPT

manual) was flat from age 4years 0 months to 8 years 11

months. That is, in comparison to all the other tests of the

SIPT, the mean score for PRN did not change over this

age range. In order to test this, an adapted administration

was developed in which children were held in place in

an adult’s lap, while sitting on the nystagmus board for

The Vestibular Bilateral Integration Pattern: A Unique Contribution to Sensory Integration Theory & Practice


Article

10 Volume 24 | No 1 | 2014

testing. Since there were no significant differences in the

PRN reflex in the standard versus held administrations, it

was determined that this method of testing would be valid.

Then, children aged 2 to 47 months were tested with

the adapted procedures. Since the mean scores for the

children under age 4 was not significantly different from

the mean scores published for 5 year olds in the SCPNT

manual, it was determined that this test can be used for

infants and toddlers with comparison to the SIPT 4 year

old norms (Mailloux, et al., in press).

Additional consideration of the Vestibular Bilateral and

Sequencing pattern also continues. Mulligan (2010)

reported that, “children with low-duration PRN scored

more poorly than children with average or prolonged

PRN on other SIPT tests measuring aspects of vestibular

function...” and she suggested that her results contribute

to “evidence supporting the PRN test’s valid¬ity as a

measure of some aspects of vestibular functioning” p 97).

In addition, Koester, et al. (in press) examined performance

on the SIPT in a sample of children with cochlear implants

and found a significant presence of the Vestibular Bilateral

Integration and Sequencing pattern in their sample.

Clinical Implications An understanding of the Vestibular Bilateral Integration and

Sequencing pattern is essential for occupational therapists

who work with children. This constellation of difficulties

is common among children referred for assessment of

sensory integrative concerns. For example, in our 2011

study, 98 children (over 38%) had shortened duration

PRN. The fact that most of these children did not have

any other diagnosis (nearly 80%) suggests that they were

not likely to have been identified for receiving services,

prior to their occupational therapy assessment of sensory

integration.

Characteristics of the Vestibular Bilateral Integration PatternThe research on constellations of sensory integration

function and dysfunction, as well as clinical experience,

suggests the following common signs that a vestibular

bilateral integration problem may be present:

• Shortened duration PRN

• Low muscle tone

• Difficulties in positions requiring extension, such as

assuming and maintaining a prone extension posture,

holding the head and upper body upright while sitting

for extended periods (such as at school).

• Poor ocular control

• Difficulty with righting or equilibrium reactions

• Inadequate balance or over dependence and on vision

for assuming and maintaining balance

• Delayed or lack of well-established laterality

• Difficulty or hesitancy in tasks involving crossing the

body midline

• Trouble with directionality or spatial orientation

• Poor bilateral integration, noted in observations and/or

test scores

• Difficulty with regulating state of arousal that seems

especially related to opportunities for movement

• A tendency to seek and enjoy large amounts of motion

without typical signs of dizziness

• The above signs are present in the absence of broader

signs of dyspraxia and somatosensory dysfunction.

If the above signs exist alongside other signs of

somatosensory and practic dysfunction, then these

vestibular bilateral signs are considered part of a

broader somatodyspraxia pattern.

Assessment of Vestibular Bilateral Integration FunctionsThe SIPT provide strong ability to identify the Vestibular

Bilateral Integration pattern and to discriminate this

pattern from other common patterns of sensory

integrative dysfunction. Structured and unstructured

observations of the child, as well as caregiver interviews

and questionnaires also help to identify this pattern. The

strongest indicators of the presence of the Vestibular

Bilateral Integration pattern include:

Below average scores on the following standardized tests

of the SIPT:


Volume 24 | No 1 | 2014 11

• Postrotary Nsytagmus (PRN)

• Standing and Walking Balance (SWB)

• Bilateral Motor Coordination (BMC)

• Sequencing Praxis (SPr)

• Oral Praxis (OPr)

• Graphesthesia (GRA) and/or Manual Form

Perception (MFP)

• Motor Accuracy (MAc)

Other standardized tests of balance (such as on

developmental tests) or bilateral coordination (such as on

the Bruininks-Oseretsky (BOT)-2, Bruininks & Bruininks,

2005) may also assist in identifying this pattern.

The following observed or reported behaviors may also be

indicators:

• Poor ability to assume or maintain a prone extension

posture for age

• Difficulty with co-ordination of head and eye movements

• Tendency to lose balance or to lack age appropriate

righting and equilibrium reactions

• Trouble learning or performing upper extremity bilateral

tasks such as cutting, folding or tying or with full body

bilateral actions such as pedaling and steering a bicycle,

swimming or completing jumping jacks

• Right-left confusion; delayed or inconsistent

development of handedness; trouble with directionality

in forming letters or in navigating through space

• Lack of dizziness after activities that involve rotary or

orbital motion

Intervention for Problems in Vestibular Bilateral Integration

Children who have been identified with vestibular bilateral

integration problems will benefit from individually tailored

intervention which provides opportunities for active, self-

directed engagement movement activities. Specialized,

suspended equipment that provides motion in all planes

and that can be self-propelled is essential. For example,

net or Spandex swings in which a children can lie

prone and propel themselves with their hands on a mat;

“helicopter” or stirrup type swings in which children can

sit and run to launch themselves into orbital motion; or

tire swings on which children can sit or lie and activate

both linear and rotary movement are all excellent ways

for a child to participate in vestibular based therapeutic

activities. As with all forms of ASI intervention, it is critical

that the core principles of this approach are present,

including employing a purposeful, playful and self-directed

atmosphere where equipment is arranged in a safe way

that provides a just-right challenge with opportunities for

adaptive responses.

ConclusionAs noted by Ayres and others, the presence of vestibular

based problems in children with learning difficulties may be

as high as 50%. Given the likely prevalence of vestibular

based difficulties in children who are struggling in school

or in other aspects of childhood occupation, awareness

and understanding of the vestibular bilateral integration

pattern are important considerations for occupational

therapists assessing and treating sensory integration

concerns.

REFERENCES:

Ayres, A. J. (1954). Ontogenetic principles in the development

of arm and hand functions. American Journal of Occupational

Therapy, 8, 95-99.

Ayres, A. J. (1955a). Proprioceptive facilitation elicited through

the upper extremities. American Journal of Occupational Therapy,

9, 1-9, 57-58, 121-126.

Ayres, A. J. (1955b). A pilot study on the relationship between

work habits and workshop production. American Journal of

Occupational Therapy, 9, 264-276.

Ayres, A. J. (1957). A study of the manual dexterity and workshop

wages of thirty-nine cerebral palsied trainees. American Journal of

Physical Medicine, 36, 6-10.

Ayres, A.J. (1964). Tactile functions: Their relation to hyperactive

and perceptual motor behavior. American Journal of Occupational

Therapy, 18 (1), 6-11.

Ayres, A.J. (1965). Patterns of perceptual-motor dysfunction in

children: A factor analytic study. Perceptual and Motor Skills, 20,

335-368.

Ayres, A.J. (1966a). Interrelations among perceptual-motor



12 Volume 24 | No 1 | 2014


abilities in a group of normal children. American Journal of

Occupational Therapy, 20 (6), 288-292.

Ayres, A.J. (1966b). Interrelationships among perceptual-motor

functions in children. American Journal of Occupational Therapy,

20 (2), 68-71.

Ayres, A.J. (1969). Deficits in sensory integration in educationally

handicapped children. Journal of Learning Disabilities, 2 (3), 44-

52.

Ayres, A.J. (1971). Characteristics of types of sensory integrative

dysfunction. American Journal of Occupational Therapy, 25 (7),

329-334.

Ayres, A.J. (1972a). Improving academic scores through sensory

integration. Journal of Learning Disabilities, 5, 338-343.

Ayres, A.J. (1972b). Sensory Integration and Learning Disorders.

Los Angeles: Western

Psychological Services.

Ayres, A.J. (1972c). Southern California Sensory Integration Test

Manual. Los Angeles: Western Psychological Services.

Ayres, A.J. (1972d). Types of sensory integrative dysfunction

among disabled learners. American Journal of Occupational

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Ayres, A.J. (1975). Southern California Post Rotary Nystagmus

Test Manual. Los Angeles: Western Psychological Services.

Ayres, A.J. (1977). Cluster analyses of measures of sensory

integration. American Journal of Occupational Therapy, 31 (6),

362-366.

Ayres, A.J. (1978). Learning disabilities and the vestibular system.

American Journal of Occupational Therapy, 11 (1), 150-161.

Ayres, A.J. (1979). Sensory Integration and the Child. Los

Angeles: Western


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Bundy, A.C. & Murray, B. (2002). Sensory integration: A. Jean

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F.A. Davis

Carrasco Koester, A., Mailloux, Z., Baltazar Mori, A., Geppert

Coleman, G., Muhs, J., Blanche, E.I., ... & Cermak, S. (in press).

Sensory integration considerations for children with cochlear

implants. American Journal of Occupational Therapy.

Davies, P. L., & Tucker, R. (2010). Evidence review to investigate

the support for subtypes of children with difficulty processing and

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Fisher, A. G. & Murray, E. A. (1991). Introduction to sensory

integration theory. In In A. G. Fisher, E. A. Murray & A. C. Bundy

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Mailloux, Z. Leao, M, Sochting, E., Baltazar Mori, A., Smith

Roley, S., Becera, T..., & Cermak, S, (in press) Modification of

the Postrotary Nystagmus Test for Evaluating Young Children.

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Mailloux, Z., Mulligan, S., Smith Roley, S., Blanche, E., Cermak, S.,

Coleman, G., ...& Lane, C. (2011) Verification and Clarification of

Patterns of Sensory Integrative Dysfunction. American Journal of

Occupational Therapy.65 (2). 143-151

Mulligan, S. (1998). Patterns of sensory integration dysfunction:

A confirmatory factor analysis. American Journal of Occupational

Therapy, 52, 819-828.

Mulligan, S. (2000). Cluster analysis of scores of children on

the Sensory Integration and Praxis Tests. Occupational Therapy

Journal of Research, 20(4), 256-270.

Mulligan, S. (2010). Validity of the Postrotary Nystagmus Test for

measuring vestibular function. OTJR: Occupation, participation,

and health, 31(2), 97-104.


Volume 24 | No 1 | 2014 13

Spandex swings in which a child can lie prone and propel themselves with their hands on a mat; “helicopter” or stirrup type swings in which children can sit and run to launch themselves into orbital motion; or tire swings on which children can sit or lie and activate both linear and rotary movement are all excellent ways for a child to participate in vestibular based therapeutic activities.


INTRODUCTION TO CASE

A little girl G is 6 years 11 months and was referred to the

Occupational therapist with the following difficulties:

STRENGTHS

Loving and helpful

Tells stories to others

Developmental milestones within norm

ADL TASKS

She is finding it difficult to eat with a knife and fork

Experience difficulties with fasteners

SCHOOL TASKS

She still confuses left and right

During writing tasks she swaps hands

Poor cutting skills

Rushes work

PLAY ACTIVITIES

Clumsy on the playground

Bump into things

BEHAVIOUR

Seeks attention and easily frustrated

Language skills good, but maths weaker

Poor task endurance and concentration

Emotional

Strategies for Clinical Reasoning

By Janine van der Linde, M.Sc. OT (Wits)

BILATERAL INTEGRATION AND SEQUENCING DYSFUNCTION:

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14 Volume 24 | No 1 | 2014


Volume 24 | No 1 | 2014 15

Bilateral Integration and Sequencing Dysfunction:Strategies for Clinical Reasoning

Results of the SIPT test

CLINICAL OBSERVATIONS: Observations only include those that obtained a score of 2 or less.

Slow movements: Sec: 8 2 Coordination and rhythm poor, better out, then drop arms and fast back.

Diadokokinesia Movements stiff loses sequence.

Right (_7_times) 2

Left (_6_times) 1 Floppy.

Both (_3_times) 1 Deliberate, moves feet with hands, loose sequence ++

Thumb-Finger touching

Right 2 Finger opposition fair, effort ++ deliberate touching, looks.

Left 2

Both 1 Separate left and right, loses place of fingers.

Co-contraction

Upper limbs 2 Uses whole body, fixes shoulders, holds onto table very strong.

Neck 2

Prone extension: sec: 8 1 Effort to hold. Assumes well.

Supine flexion posture sec: 18 2 Neck tired a bit.

Schilder’s arm extension test

Involuntary movements 1 Can’t stand still with eyes closed, body sways ++++

Postural changes 1 Arms and feet move. Fixes shoulder girdle, difficult to keep arms up.

Trunk rotation 1 Arms move with head.

Hyperactivity 1

Tactile defensiveness 2 Slight and orally sensitive also.

Postural background movements 2 Slightly excessive.

left ... or right?


The Occupational therapist (OT) hypothesizes that the

child may have a Bilateral Integration and Sequencing

dysfunction (BIS).

In studying the SIPT results and looking at the clinical

observations the therapist will be able to gain more

information on the child’s functioning and will be able to

confirm or refute this diagnosis.

The SIPT was developed as a diagnostic and descriptive

tool to assess praxis and the sensory processing of the

different senses and how these difficulties manifest in

behavioural issues (Ayres, 2004, Asher et al., 2008).

It is currently the golden standard in the testing of sensory

integration function, as it was found to have the ability to

discriminate between children with learning disabilities and

the typical population and proved to be very reliable and

valid (Asher et al., 2008).

Using the SIPT requires specialist training and a

good understanding of sensory integration and

the neurobiological background, as well as a good

understanding of the tests and subtests.

In a study by Asher and Parham (2008) on the inter-rated

validity of the SIPT they emphasised that the ability to

make a reliable diagnosis was related to prior training in

using the assessment tool and in using specific strategies

in decision making for a final diagnosis (Asher et al., 2008).

This article will look at a step by step approach/strategies

in determining the final pattern of SI dysfunction taking into

account all the information from the assessments.

GROSS MOTOR: Scoring out of 5

Kneel, wal, forward / 4 Fast, but OK.

backward 2 Sways +++ poor hip extension. Fair.

Galloping 4 Rhythm and jerky, a bit poor. Taught.

Skipping 4 Rhythm and jerky, a bit poor. Taught.

Ipsilateral leg slap 3 Bilateral motor fair but co-ordination jerky.

Contralateral leg slap 1 Can’t, with teaching improved, but difficult to sustain.

Star jump 5 Taught.

Stride jump 1 Cant jump side to side.

Long jump 5 Good take off and land.

Hopping R 4 Left weaker. Effort to do it.

L 2

Jump hop sequence 2 2 seq. correct, can’t sustain movement pattern.

Bounce a ball 5 Good.

Throwing 4 Fair.

Catching 4 Fair.

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STEP 1: LOOK AT THE SIPT BAR GRAPH TO DETERMINE THE PROBLEM AREASSee bar graph in case background

A study by van Jaarsveld (2012) investigated whether the SIPT is appropriate for use with the South African population.

This study showed that 12 of the 17 tests compare well against the normative US sample, but found that South African

children within the age band 6y 0m – 8y 11m performed significantly better on Design copying, Oral Praxis, Bilateral motor

co-ordination, Standing and walking balance and Motor co-ordination than the US sample. These five tests therefore needs

to be adapted with ½ a standard deviation unit to the negative side when interpreting the SIPT scores of local children (Van

Jaarsveld et al., 2012).

As G falls within this age band (6 years 11 months) the scores needs to be adapted according to the recommendations

made by van Jaarsveld.

STEP 2: ADAPT DC, OPr, BMC, SWB & MAC scores with 0.5 SD to the negative side


Volume 24 | No 1 | 2014 17

Space Visualization -1.63 Figure-Ground Perc 0.79 Man. Form Perception -1.42

Kinethesia N/A Finger Identification 0.45 Graphethesia -0.16 Loc. Tactile Stimuli 1.24 Praxis Verb. Command -0.25 Design Copying -1.92

Constructional Praxis -0.90 Postural Praxis 0.74 Oral Praxis -1.98 Sequencing Praxis -1.56 Bilateral Motor Co-ord -1.59

Stand & Walk Balance -1.93 Motor Accuracy -1.91 Postrotary Nystagmus -1.55

SD LOW AVERAGE HIGH-3 -2 -1 0 -1 -2 -3

Percentile

0.5 1 5 10 25 50 75 90 95 99 99.5


STEP 3: FIND ALL THE TEST SCORES BELOW -1.0 SD

After adapting the scores look at all the subtests to determine the scores falling below -1.0SD.

In this specific case the following scores were found to be low:

SV -1.64 OPr -1.98 SWB -1.93 SVCU -1.37

MFP -1.42 SPr -1.56 MAC -1.91 PHU -2.84

DC -1.92 BMC -1.59 PRN -1.55

These results then lead to two questions: What does low scores in these subtests mean?

How do these scores fit in with the patterns of SI dysfunction?

STEP 4: DETERMINE IF THE SCORES FIT WITH PATTERN OF SI DYSFUNCTION

Over the years various factor analysis and cluster analysis were done to determine sensory integration patterns. It is of value

to understand how this evolved as this helps to understand the current patterns that are found.

The discussion will mostly focus on the bilateral integration and sequencing dysfunction patterns.

Various studies by Ayres, Fisher, Bundy, Mulligan and Mailloux et.al tried to determine and verify the different patterns of

sensory integration (Ayres, 2004, Fisher et al., 1991, Mulligan, 1998, Bundy et al., 2002, Mailloux and Parham, Mailloux et

al., 2011). Bilateral Integration and Sequencing deficits (BIS) were consistently identified as one of the patterns seen with

the results of the SIPT test.

Initially it was Ayres who found that BIS was linked to a postural ocular movement disorder (Ayres, 2004). Ayres described

bilateral integration and sequencing as a dysfunction that include poor postural abilities, decreased muscle tone and

decreased bilateral motor coordination. She considered it to be a type of motor coordination disorder and associated it

with vestibular functions although she did not necessarily consider it a dyspraxia. In a factor analyses by Ayres in 1989 the

following tests indicated a bilateral integration and sequencing pattern (Ayres, 2004).

The low scores on the following tests indicated a BIS dysfunction:

OPr SPr GRA BMC SWB MFP

Fisher (1991) then further investigated bilateral integration in terms of the influence of motor control and motor learning

theories on motor and cognitive components of movement (Fisher et al., 1991). She used motor learning theories to look

at the relationship between vestibular and proprioceptive systems in praxis. This discussion brought forward terms such as

feed-forward and feedback and hypothesized that postural control, ocular motor control and projected action sequences

accompanied by BIS can result in praxis deficits (Fisher et al., 1991).

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In a large study by Mulligan (1998) factor and cluster analysis found similar patters namely: Bilateral Integration and

Sequencing, Somatosensory, Visuo-praxis and Dyspraxia (Mulligan, 1998). She found an overarching pattern of general

SI problems and recommended that these patterns should rather be seen as having a general practice dysfunction with a

weakness in a specific area e.g. bilateral integration. Further recommendations in this study also looked at the influence of

specific subtests that are weak in terms of retest reliability (Mulligan, 1998).

The following subtest were said to indicate a pattern of BIS (Mulligan, 1998)

OPr SPr GRA BMC SWB KIN

Bundy et.al (2002 p6) introduced the view of BIS as a practice disorder(Bundy et al., 2002). They still associated BIS

with difficulties in vestibular and proprioceptive input, but also viewed BIS as a practice disorder, but less severe than

somatodyspraxia.(Bundy et al., 2002).

In the latest research by Mailloux et al (2011) they found similar patterns, but described that a dysfunction of Vestibular and

Proprioceptive Bilateral Integration and Sequencing has emerged. No evidence of underlying practice difficulties was found

in this analysis for BIS. (Mailloux et al., 2011)

The factor and cluster analysis found a Vestibular and Proprioceptive Bilateral Integration and sequencing pattern that

showed high loadings on the following subtest:

- Oral Praxis (OPR)

- Standing walking balance (SWB)

- Post rotary Nystagmus (PRN)

- Bilateral motor coordination (BMC)

- Motor Accuracy (MAC)

OLD PATTERNS NEW PATTERN EMERGED (Mailloux et al., 2011)

↓ Opr score OPr score

↓ SPr score SPr score

↓ BMC score ↓ BMC score

↓ GRA score SWB score

↓ PPr may be low PRN score

MAC score

↓ KIN score

↓ SVCU score SVCU score

A new finding was the fact that MAC clusters with this group. This test reflects eye hand coordination in a variety of

postures and positions and integration of two sides of the body. Mailloux, et al., (2011, p. 148) found that it “reflect the

vestibular and bilateral functions needed for the coordination of eye, head, and hand movements; postural adjustments; and

crossing of body midline needed in this test.” (Mailloux et al., 2011). KIN only loaded modestly with this group, reflecting the

proprioceptive involvement in the BIS dysfunction. (Mailloux et al., 2011)


Volume 24 | No 1 | 2014 19


This study confirmed Ayres view that a shortened PRN can be linked with bilateral integration problems and vestibular

difficulties; however, the recent study did not find an association between measures of directionality, crossing midline and

laterality with this pattern of dysfunction. (Ayres, 2004, Mailloux et al., 2011)

If you then compare all the scores found on the SIPT the case will look like this.

Visuopraxis Visual VBIS Somatopraxis Praxis Perception on Verbal difficulties command

SV -1.63 Form and Space BMC -1.59 High Loadings PrVC Low -0.25

MFP -1.42 SV -1.63 SPr -1.56 PPr 0.74 PRN - 1.55

DC -1.92 FG 0.79 Opr -1.98 OPr -1.98 (Need average to high)

CPr -0.90 SWB -1.93 SPr -1.56 Poor Sequence

FG 0.79 Visual Praxis PRN -1.55 BMC -1.59 Possible Low

DC -1.92 MAC -1.93 GRA -0.16 Scores

CPR -0.90 GRA -0.16 Strong Indicator BMC -1.59

MAC -1.92 Moderate Link SPr -1.56

KIN : Not tested Lower Loadings Opr -1.98

Haptic Form SVCU -1.37 PrVC -0.25 SWB -1.93

↓ and Space PHU -2.84 CPr -0.90 DC -1.92

MFP -1.42 SWB -1.93

GRA -0.16 FI 0.45

↓

The SIPT test scores indicate that the child has bilateral integration and sequencing dysfunction. These scores showed

the involvement of the vestibular in the low PRN score, but observations made in clinical observations can add further

confirmation.

STEP 5: CLINICAL OBSERVATIONS

Looking at the unstructured clinical observations it is necessary to look for evidence that support difficulties in vestibular

processing, proprioceptive processing and bilateral integration and sequencing difficulties.

Vestibular processing

Some vestibular processing difficulties can be seen in vestibular ocular responses and postural control. Vestibular ocular

responses include stabilization of eyes and head during movement, coordination of head and eye movements with neck

and body stabilization and gaze stabilization during movement (Smith Roley et al., 2001). Vestibular influences on postural

control include postural tone (especially extensor muscle tone) and balance reactions. It contributes to the child’s awareness

Article

20 Volume 24 | No 1 | 2014


of his body position and movement through space, and to a child’s ability to stabilize the eyes when the head is moving

(Smith Roley et al., 2001).

Trunk stability is also associated with bilateral integration as the trunk needs to be stable to assist limbs to dissociate from

the trunk when moving.

It is also important to look at eye movements, postural tone, and equilibrium reactions, righting reactions, protective

extension and dissociation between head and body. The ability to assume and maintain a totally extended posture against

gravity is hypothesized to require adequate processing of gravity information via the vestibular nuclei (Fisher et al., 1991).

Flexing the neck in the supine flexion position the vestibular-proprioceptive system facilitates righting of the head and upper

trunk. Postural background movements can also be an indication of difficulties with vestibular processing and is closely

related to muscle tone, residual activity of primitive reflexes, equilibrium reactions and proximal stability.

Proprioceptive processing

The discriminative function of proprioception is the basis of body scheme and plays a role in the spatial orientation of our

bodies or body parts in space, the rate and timing of our movements, how much force our muscles are exerting, postural

control (including muscle tone) and produces co-ordinated movements.

Difficulties in proprioceptive can be seen in the following clinical observations: TFT (look at how hard the child presses, uses

excessive vision), Finger nose test (inaccuracy of movements, needs to use vision), Schilder’s Arm Extension (want to

open eyes, spoon or fix in hands). Decreased awareness of position of limbs) and Slow movements (unaware of position of

arms and grading of movement is poor (Blanche et al., 2012).

Other unstructured observations may include postural control mechanisms i.e. tone, grading of force, speed and timing of

movements e.g. during ball games or tension in the pencil grip, pressure exerted on the pencil when drawing (Blanche et al.,

2012).

Bilateral integration

Children with bilateral integration and sequencing difficulties may experience difficulties with crossing of the midline, left/

right discrimination, difficulty in sustaining the movement pattern sequence, cutting with scissors, eating with knife and

fork, shoelaces/buttons/fasteners. In the clinical observations test you can look at the DDK and TFT test and the difference

between left, right or when doing it with both hands together. Ayres proposed that the ability to cross the midline of the body

is an indication of how well both sides of the body have become integrated (Blanche et al., 2012).

Projected action sequences also plays a role in bilateral integration and sequencing as it requires the ability to plan

movements in response to changing events in the environment (Bundy et al., 2002). Catching a bounced ball and jumping

into a series of squares placed on the floor are examples of this as it requires the child to control their movements before

they can move in relation to the environment (Fisher et al., 1991). This movement is built on an internal model of the world

and dependent on previous experiences (feed-forward). Feed-forward is used to detect wrong patterns in movement

before the actual movement is started. It is therefore associated with the planning and execution of bilateral motor action

sequences (Fisher et al., 1991).


Volume 24 | No 1 | 2014 21


STEP 6: FINAL CONCLUSION (Brining it all together)

Bilateral integration is defined by Bundy (2002 p.8) as “Difficulty using two sides of the body in co-ordinated fashion

and sequencing motor actions” (Bundy et al., 2002). This may require activities that require symmetrical, alternating or

asymmetrical task.

In order for a diagnosis of BIS to be made, there should be a meaningful cluster of low SIPT scores on OPr, SPr, BMC,

SWB, PRN and MAC.

Bringing it all together and linking with presenting problems.

Evidence Supporting Dysfunction Evidence Refuting Dysfunction SIPT

↓ BMC -1.59 Moderate link KIN : Not tested

↓ SPr -1.56 GRA -0.16

↓ Opr -1.98

↓ SWB -1.93

↓ PRN -1.55

↓ MAC -1.93

Moderate link KIN : Not tested

SVCU -1.37

↓ PHU -2.84

Clinical Observations

Slow movements: poor proprioception in control Good eye movements

of arm movements, rhythm poor Good tracking across midline

DDK: worse with both hands, loose sequence Good dissociation

TFT: worse with both hands, uses + visual input Ipsilateral leg slap: bilateral motor coordination fair

Prone extension: poor postural tone, Throwing and catching a ball: fair

effort to maintain Bounce a ball: good

Schilder’s arm test: sway unable to keep still

Galloping & skipping: poor rhythm

Hopping: left weaker

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Presenting problems

Difficulty to eat with a knife and form Loving and helpful

Difficulties with fasteners Language skills good but maths weaker ???

Confuses left and right.

Poor coordination with left and right

Poor cutting skills

Clumsy on playground

Bump into things

During writing tasks she swaps hands

Difficulties with vestibular processing can be seen in the scores obtained for PRN (-1.55) and SWB (-1.93), as well as in

observations made such as being clumsy and bumping into things.

SWB and PRN performance reflects vestibule-proprioceptive processing and the vestibular-proprioceptive system is linked

with BIS, it could thus have an influence on BIS (Ayres, 2004). Mailloux et.al 2011 indicated that a low PRN is indicative

of hypo responsiveness to vestibular input and proof that bilateral integration problems are associated with vestibular

insufficiencies (Mailloux et al., 2011). G is clumsy and bumps into things at school. The low scores on these items could

give an explanation for these observations as poor vestibular processing plays a role in postural control and balance (Smith

Roley et al., 2001).

G still confuses left and right and tends to swap hands when crossing the midline. Literature confirms that a child with

under-reactive vestibular responses often has poor integration of the two sides of the body. The child often fails to develop a

skilled hand dominance or preference and avoid crossing the midline of the body (Smith Roley et al., 2001).

Difficulties in eating with a knife and fork, dressing (doing fasteners) and organising her movements in space may be as a

result of poor body scheme and proprioception. G was also observed to experience difficulties with grading force and speed

of movements. These functional difficulties would thus support a hypothesis of dysfunction of the proprioceptive system.

G found some tasks that required bilateral projected action sequences such as star jumps, ipsilateral stride jump and

jumping sequences, hard to execute with good coordination. She was able to jump with both feet into consecutive squares

but was unable to perform it accurately and in a smooth and rhythmic manner, indicating a problem with projected action

sequences. She did however do well with timing the catching and throwing of a ball.

G had difficulty with both the pattern and rhythm when performing DDK and TFT and the execution of these tasks bilaterally

decreased. She also relied on her vision and used a lot of pressure to provide feedback during the activities.

A low score (-1.56) on the SPr test can be an indication of difficulties with sequencing, as the task requires the ability to

complete a series of hand and finger movements (Ayres, 2004). Other difficulties with sequencing could be observed in the

DDK and TFT tests and in the execution of the gross motor tasks.

Difficulty with BIS will have an influence on hopping, skipping, jumping, star jumps as well as symmetrical and reciprocal

stride jumping (Murray-Slutsky and Paris, 2000). G experienced difficulty in executing these tasks.

Further confirmation of the difficulties with BIS is in the low score (-1.59) obtained for BMC. This test measures the ability of

the hands and feet to move together in a smooth and rhythm way. The motor demands on this test includes the smoothness

of the movement, rhythm, sequencing and timing (Ayres, 2004).


Volume 24 | No 1 | 2014 23


24 Volume 24 | No 1 | 2014

The SIPT scores indicate a cluster of low scores that fit with the pattern of

Vestibular Bilateral Integration and Sequencing dysfunction (Mailloux et al., 2011).

The presenting problems of having difficulty to eat with a knife and fork, experience

difficulties with fasteners, confusion of left and right, swapping hands during

writing tasks, poor cutting skills and being clumsy could be linked to an underlying

vestibular, proprioceptive processing difficulties that result in a bilateral integration

and sequencing dysfunction.

REFERENCES:

ASHER, A. V., PARHAM, L. D. & KNOX, S. 2008. Interrater reliability of Sensory Integration

and Praxis Tests (SIPT) score interpretation. Am J Occup Ther, 62, 308-19.

AYRES, A. J. 2004. Sensory Integration and Praxis test manual, Los Angeles, Western

Psychological services.

BLANCHE, E. I., BODISON, S., CHANG, M. C. & REINOSO, G. 2012. Development of the

comprehensive observations of proprioception (COP): validity, reliability, and factor analysis.

Am J Occup Ther, 66, 691-8.

BUNDY, A. C., LANE, S. J. & MURRAY, E. A. 2002. Sensory Integration: Theory and

Practice., Philadelphia, F.A. Davies Company.

FISHER, A. G., MURRAY, E. A. & BUNDY, A. C. 1991. Sensory Integration: Theory and

Practice, United states of America, Davis Company F.A.

MAILLOUX, Z., MULLIGAN, S., ROLEY, S. S., BLANCHE, E., CERMAK, S., COLEMAN, G.

G., BODISON, S. & LANE, C. J. 2011. Verification and clarification of patterns of sensory

integrative dysfunction. Am J Occup Ther, 65, 143-51.

MAILLOUX, Z. & PARHAM, L. D. Sensory Integration. In: CASE-SMITH, J. & O BRIEN, O.

(eds.) Occupational Therapy in Children. 6th Edition ed. Missouri: Mosby Elsevier.

MULLIGAN, S. 1998. Patterns of Sensory Integration Dysfunction: A Confirmatory factor

analysis. The American Journal of Occupational Therapy, 52, 819-825.

MURRAY-SLUTSKY, M. S. & PARIS, B. 2000. Exploring the Spectrum of Autism and

Pervasive developmental disorders, USA, Therapy Skill builders.

SMITH ROLEY, S., BLANCHE, E. I. & SCHAAF, R. C. 2001. Understanding the nature of

Sensory Integration with Diverse Populations, USA, Therapy Skills Builders.

VAN JAARSVELD, A., MAILLOUX, Z. & HERZBERG, D. S. 2012. The use of the Sensory

Integration and Praxis test with South African children. The South African Journal of

Occupational Therapy, 42.


A Special thank you to Ray Anne Cook for her assistance in providing a suitable case study for this article.


The activities are divided into three groups:1. Activities to enhance symmetrical functioning

2. Activities to enhance alternating functioning

3. Activities to enhance midline crossing

(to be published in the next newsletter)

Grading:A. Symmetrical use of the whole body

B. Symmetrical use of lower extremities

C. Symmetrical use of upper extremities

Further grading according to positioning, namely from prone to

stand; from shoulder girdle to wrist; as well as from isometric

and isotonic movements.

Equipment:1. Bolster swing

2. Inner tubes

3. Scooter board

4. Hammock

5. Balance board

6. Trapeze swing

7. Flexion swing

Activity ideas

Suggested Activities for the Improvement of Bilateral IntegrationBy Esta Steenkamp

Volume 24 | No 1 | 2014 25

(This article was first published in the SAISI Newsletter of January 1986)


26 Volume 24 | No 1 | 2014

1. ACTIVITIES TO ENHANCE SYMMETRICAL FUNCTIONING

A. ACTIVITIES TO ENHANCE SYMMETRICAL USE OF THE WHOLE BODY

A.1 Bolster SwingProne: Isotonic: Lie over bolster, kick away from wall and throw a ball in the “fish pond”

or over the wall. Lie over bolster, pull on stick or rope and move

backwards and forwards through symmetrical movements of extremities.

Sitting: Isotonic: Sit with legs across bolster and swing by pulling rope.

Sit, hold on with legs and row bilaterally.

Sit, hold on with legs and throw and catch balls; or throw balls through

hoopla hoop; or hold stick with both hands and hit balls.

Sit on edge of bolster, hold on with hands and kick a ball.

Sitting: Isometric: Two sit on bolster, hold on with legs and push against each other

with palms of hands.

Kneeling: Isometric: Kneel and hit ball with head.

Standing: Isotonic: Child swings bolster and pulls him/herself up and hang with legs flexed.

A.2 Inner Tube:Prone: Isotonic: Lie on tummy over vertically suspended tube.

Kick away from wall, or push away with hands

from wall.

Lie on tummy and pull with both hands on rope

or stick, or throw balls in a “dam”.

Swing forwards and push blocks over using

both hands.

Sitting: Isotonic: Sit in swinging tube and hold on to trapeze

with both hands.

Kick medicine ball using both feet.

Sit on vertically suspended tube and bunny hop

through tube while holding onto trapeze.

Sit in tube, holding on with legs and hit a ball

with a stick using both hands.

Put tube flat on floor and let child jump like a frog

with legs across the tube.

Kneeling: Isotonic: Hold tube in vertical position and roll forwards.

Child dives through.

Place tube flat on floor: child jumps up and down

on knees.

Squatting: Isometric: Child is in squat position on tube and therapist

pulls child over floor.

Standing: Isotonic: Run and jump into tube covered with thick material

like blankets and pillow in the middle.

Swing on trapeze and land inside tube.

Tube can be on different heights to use more isometric

flexion in elbow joints.

Build an obstacle course with varying sized tubes.

Child jumps from the one to the other, forwards,

backwards and sideways, clapping hands in between.


Volume 24 | No 1 | 2014 27

Activity ideas

A.3 Scooter BoardProne: Isotonic: Lie with legs extended and use arms in symmetrical movements patterns:

ride and throw sponges into a container or towards a target; ride into a

crash mat with both arms pushing it away.

Lie on scooter board and push with both hands and feet.

Ride down ramp and hit shapes, sponges, road signs etc.

simultaneously on both sides.

Prone: Isometric: Lie and hold onto a friend’s legs while on scooter board.

Holding onto big bag or stick, go and “deliver” goods.

Pull child, turn and let him roll onto a mattress.

Sitting: Isotonic: Move with legs and pull on rope with hands bilaterally

to “cross the river”.

Sitting: Isometric: Sit and hold on while being pulled with a stick/rope.

A.4 HammockProne: Isometric: Use heavy additional equipment like big balls etc.

Prone: Isotonic: Kick away from wall and throw a ball through a

hoopla hoop.

Kick away with feet and if possible on the opposite

side, push away with the hands.

Sitting: Isotonic: Sit in hammock and shift forwards and backwards by

supporting with hands bilaterally and moving with feet.

Standing: Isometric: Swing to and fro in standing position.

A.5 Balance Board(Alternating isometric and isotonic contraction)

Prone: Lie while throwing and catching a ball.

Sitting and kneeling:

Sit and maintain balance whilst taking part in

eye-hand coordination activities, e.g. throwing

bean bags to a target etc.

A.6 TrapezeSitting: As combined in previously

mentioned activities.


28 Volume 24 | No 1 | 2014

1. ACTIVITIES TO ENHANCE SYMMETRICAL FUNCTIONING

B. ACTIVITIES TO ENHANCE SYMMETRICAL USE OF LOWER EXTREMITIES

Prone or supine: Lie on back and kick a suspended ball.

Lie on back or tummy on scooter board and propel with legs.

Lie on back and kick away from wall, ride off the ramp and

kick down a heap of sponges.

Sitting: Sit on cardboard and move forwards/backwards using legs.

Sit and pick up bean bags with feet. Grade the weight of

these objects. Sit on scooter board and propel with legs in a

symmetrical movement pattern.

Standing: Bunny hops.

Jumping on trampoline: forwards, backwards, sideways, with eyes

opened/closed, to and fro over line, over different heights.

Shoulder Movements: Isotonic: Rhythmical exercises with music.

Obstacle courses with big apparatus.

Stick used in bilateral handling, to row, to hit etc.

Sit on bolster and pull on knotted rope or trapeze

Swimming breast stroke or butterfly in swimming pool.

Pillow fight.

Lie over ball, bolster, or in vertically suspended tube.

Pick up bean bags/sand bags and throw through

hoopla hoop/over wall/in pond.

Skipping rope activities.

Animal jumps, e.g. frog jumps.

Angels in the snow.

Bilateral blackboard patterns.

Hit cymbals, drums, other musical percussion

instruments.

Bounce a ball.

Put a ball in the middle of a blanket. Two children take

two corners of the blanket each and “bounce” the ball

up and down without touching the ball.

Shoulder movements: Isometric: “Push wall over” with two hands together.

Hang onto rope or net or trapeze.

Sit in a box, or on a scooter and therapist pulls child

whilst holding on to stick with both hands.

Pull someone else around.

Elbow movements: Isotonic: Sand with sandpaper.

Tearing pages from a magazine.

Arm movements on music.

Finger paint or paint with two big brushes.

Catching and throwing a ball.

Elbow movements: Isometric: Wheelbarrow walk.

Swing on trapeze with maintained elbow flexion.

Wrists and hands: Isotonic: Pronation/supination; finger adduction/abduction,

flexion/extension.

Paper collages.

C. ACTIVITIES TO ENHANCE SYMMETRICAL USE OF UPPER EXTREMITIES


Volume 24 | No 1 | 2014 29

Grading:

1. From prone to standing positions where much

more balance and equilibrium skills are required.

2. Activities are more isotonic in nature.

2.1 Bolster SwingProne: Lie on tummy and row with alternating arms to propel

self forward. If swing is low enough, child can also

push him/herself forward with hands alternately

pushing on floor.

Sitting: Sit on bolster while objects are being thrown to the

child from different directions so that he/she has to

catch it with alternating hands.

2.2 Scooter BoardProne:

Child pulls him/herself across the “river” with

alternating hands.

Ride down ramp and catch a ball with left and right

hands alternately.

Ride down ramp and hit sponge blocks alternating

between hands used.

2.3 HammockProne:

Child swings forward and backward, hitting objects

with alternating hands.

Crawling:

Crawl through hammock filled with sponges.

2.4 Flexion SwingSitting:

Swing and throw balls into container with alternating

hands; or hit/push other suspended equipment away

using hands alternately.

2. ACTIVITIES TO ENHANCE ALTERNATING USE OF UPPER AND LOWER EXTREMITIES

Origami.

Knitting.

Fastening and loosening of screws.

Playing with finger puppets.

Knotting ropes with fingers.

Straw constructions.

Cutting and pasting.

Play dough activities.

Rolling and tearing paper.

Playing with pegs.

Hands

Isometric use is elicited through a variety of grips, e.g.

palmar grip, pinch grip etc. whenever the hands are

holding onto an object.


30 Volume 23 | No 2 | 2013

Book Review

Below is a list of various books and articles that cover various aspects of bilateral integration and sequencing. May you find this inspiring and thought provocative.

1. Ayres, A.J. (2007). Sensory Integration and Praxis Tests

Manual. 9th Ed. Los Angeles: Western Psychological

Services.

2. Ayres, A.J. (2005). Sensory Integration and the Child.

2nd Ed. Los Angeles: Western Psychological Services.

3. Ayres, A.J. (1979). Sensory Integration and the Child.

1st Ed. Los Angeles: Western Psychological Services.

4. Bundy, A.C., Lane S.J. & Murray, E.A. (2002). Sensory

Integration Theory and Practice. 2nd Ed. Philadelphia: F.A.

Davis Company.

5. Case Smith, J. & O’Brien, J.C. (2010). Occupational

Therapy for Children. 6th Ed. Missouri: Mosby Elsevier.

6. Goddard, S. Reflexes, Learning and Behavior. (2005).

Eugene, Oregon: Fern Ridge Press.

7. Murray Slutsky, C. & Paris, B.A. (2000). Exploring

the Spectrum of Autism and Pervasive Developmental

Disorders: Intervention Strategies. Therapy Skill Builders.

8. SAISI Clinical Observations of Gross Motor Items.

(2004). SAISI.

9. Shumway-Cook, A & Woollacott, M.H. Motor Control.

Translating Research into Clinical Practice. 4th Ed.

Lippincott Williams & Wilkins.

10. Smith Roley, S, Blanche, E.I. & Schaaf, R.C. (2001).

Understanding the Nature of Sensory Integration with

Diverse Populations. Therapy Skill Builders.

Articles:

1. Mailloux, Z, Mulligan, S, Smith Roley, S, Blanche, E.I.,

Cermak, S, Coleman, G.G., Bodison, S & Lane, C.J.

(2011). Verification and Clarification of Patterns of Sensory

Integrative Dysfunction. American Journal of Occupational

Therapy, 65 (2), 143-151.

2. SAISI Newsletter Articles on Bilateral Integration and Midline Crossing:

• Sept – Dec 1986: Theoretical approaches to Manual

Crossing of the Midline of the body and Ways of

Assessment. Erica Jooste.

• VOL 5 NO.3 1994: The Meaning of Manual Midline

Crossing. Janet Stillwell.

• VOL 10 NO.1 1999: The Child with Low Postural Tone

and Minor Motor Dysfunction – Occupational Therapy

Considerations. Thea Coetzer.

• VOL 10 NO.2 1999: The Role of Sensory Systems in

the Development of Postural Control and Movement. Kate

Bailey.

• VOL 13 NO.2 2002: Occupational Therapy Intervention

with a Child with Half a Brain. A Case Study. Sally

Mackenzie.

• VOL 13 Nr 2 2003: Assessing Handedness –

Evaluating the Effectiveness of Three SIPT Tests to

Determine the Extent of Manual Specialization. Elke Kraus.

Recommended Resources for Bilateral Integration and SequencingCompiled by Rosa-Marié Olivier (Editor)


If you have not used CPD Solutions before, go to www.cpdsolutions.co.za and click on ‘Help’ to download the CPD Solutions SMS guide for instructions on how to register with your cell phone and answer multiple choice tests with an SMS.

ANSWER ALL QUESTIONS TRUE (A) OR FALSE (B)

QUESTIONNAIRE 34.1 (a19547) The Vestibular Bilateral Integration Pattern: A Unique Contribution to Sensory Integration Theory & Practice, By Zoe Mailloux, OTD, OTR/L, FAOTA1 Jean Ayres became interested in the role of the vestibular system in the 1960’s when she started to work with children with learning difficulties.

2 The lack of integration of function of the two sides of the body distinguishes the Disorder in Postural Bilateral Integration as first described by Ayres.

3 Ayres started using the Southern California Post Rotary Nystagmus Test as a measure of central processing of vestibular input in 1975.

4 A “depressed” measure of the PRN reflected a problem in the typical inhibitory influences from other neural centers on this reflex, while a “prolonged” PRN reflected inefficient processing of vestibular input in the vestibular nuclei of the brainstem.

5 Ayres revised her description of the Postural and Bilateral Integration Deficit to a Vestibular and Bilateral Integration Deficit, stating that “The symptoms of a vestibular-bilateral disorder are very subtle. These children are often considered completely normal until they enter school and have trouble with reading, arithmetic or other academic work…”

6 Ayres later stated: “ A number of studies in this country, in Australia, and in South America have shown that at least 50 percent of all children with learning or language problems have too long a duration of PRN. These findings suggest that some aspect of vestibular function is very important in meeting the demands of school-work, and this aspect is not functioning adequately in many school children today.”

7 Ayres finally iterated Bilateral Integration and Sequencing (BIS) being reflective of a pattern of sensory integrative dysfunction that was characterized by the discreet vestibular based signs with the absence of more significant tactile or praxis deficits seen in patterns such as Somatodyspraxia.

8 Mailloux, et al. published research in 2011 where the findings reinforced a long-held view of the significance of low PRN scores and validated Ayres’ (1989) theoretical assumption that bilateral integration problems and other signs of vestibular inefficiencies are associated with a shortened duration of PRN.

9 Another research project by Mailloux, et al., currently in press, identified that the PRN test can be administered to infants and toddlers using the 4 year old SIPT norms.

10 The strongest indicators of the presence of the Vestibular Bilateral Integration pattern include: Below average scores on the following standardized tests of the SIPT: Postrotary Nsytagmus (PRN), Standing and Walking Balance (SWB), Bilateral Motor Coordination (BMC), Sequencing Praxis (SPr), Oral Praxis (OPr), Graphesthesia (GRA) and/or Manual Form Perception (MFP), Motor Accuracy (MAc).

QUESTIONNAIRE 34.2 (a85978) Bilateral Integration and Sequencing Dysfunction: Strategies for clinical reasoning by Janine van der Linde, M.Sc.OT (Wits)1 A study by van Jaarsveld (2012) investigated whether the SIPT is appropriate for use with the South African population. This study showed that 5 test items have to be adapted with ½ a standard deviation unit to the positive side.

2 This adaptation of scores is for ages 6 years 0 months to 8 years 11 months only.

3 Ayres described bilateral integration and sequencing as a dysfunction that include poor postural abilities, decreased muscle tone and decreased bilateral motor coordination. She considered it to be a type of motor coordination disorder and associated it with vestibular functions although she did not necessarily consider it a dyspraxia.

4 Fischer brought forward terms such as feed-forward and feedback and hypothesized that postural control, ocular motor control and projected action sequences accompanied by BIS can result in praxis deficits.

5 A new finding was the fact that MAC does not clusters with this group. This test reflects eye hand coordination in a variety of postures and positions and integration of two sides of the body.

6 The use of clinical observations can refute the test results of the SIPT.

7 The ability to assume and maintain a totally extended posture against gravity is hypothesized to require adequate processing of gravity information via the vestibular nuclei and thus indicative of vestibular processing.

8 Grading of force in movement is indicative of the processing of the proprioceptive system.

9 Projected action sequences also plays a role in bilateral integration and sequencing as it requires the ability to plan movements in response to stable events in the environment.

10 Feed-forward is used to detect wrong patterns in movement before the actual movement is started.

CPD Programme Questionnaire

Volume 23 | No 2 | 2013 31


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