Thursday, November 20, 2008

Samonas Out Loud

I recently got Samonas sound therapy training, and I have been reading everything in site about Samonas, Therapeutic Listening and other sound programs. I want to know about the technology and how the programs differ from each other.

Over Speakers
One thing that Samonas has that others do not, is a series of disks (the CQ series) that can be played over stereo speakers. One of my colleagues uses them in the school setting with her kids once per week and sees gains.

Web-Based Monitoring
Another feature I like is even more important. The Samonas people will tell you all about the high quality music recorded in pristine settings by joyful musicians.... that's important, but even more so is the feature of web-based monitoring. After clients get their listening CD, they log into a web site every day or so and provide a rating of how it's going. Based on that day's feedback, they are told how many minutes to listen the next day.

To understand why this is important one needs to know that with some other programs, therapists give the one-size-fits-all instruction: 30 minutes, twice per day. There is no room for nuance here. It belies the fact that these therapies truly are powerful, and for people who are sensitive (typically, the people who need them), they can have powerful effects. I have seen adults and children have unwanted emotional reactions at inoportune times.

One can use the Samonas disks without the web log-in. I like the fact, that therapists are being instructed in how to grade auditory therapy ... just as they currently grade their other therapies.

Levels of Intensity
Finally, there are many levels of intensity in the Samonas program. A therapist finds out what level to start a client at by giving them the intro (A.R.T.) CD and monitoring the effects using web-based reporting. Once the client is matched to an intensity level, listening disks are chosen.

There are a myriad of other features, and more to come. I am impressed with the program, and confident that it will serve my clients well.

Abuse, Developmental Delay & IM

Here's my 3rd post today. I've been so busy with my new business, I'm behind in posting. This story is about yet another of my 11-12 year old friends. This boy was finally given the autism label just so that he could get school-based services. But in fact ... read on.

Keith is an 11 year old boy with developmental delays of uncertain origin. He was raised until the age of 4 in a home with alcohol and drug abuse as well as domestic violence. Keith’s head shows scars from serious head injuries from his early years. He was eventually removed from his birth home and provided a safe, loving home with relatives who became his legal parents. Once in school, Keith struggled in regular education classes. School Testing at the age of 9 years 6 months had shown that he was 2-4 years behind on visual motor, visual perception and motor coordination skills (Beery-Buktenica Test of Visual Motor Integration). He was provided extra help by a classroom aide, but did not qualify for supplemental services such as occupational therapy.

When Keith walked in the door for his OT evaluation at age 11, he had the look of a puppy who has been mistreated. He walked slowly, with slouched shoulders and shuffled gait. When he spoke, his words were barely audible. Dried blood on his very short fingernails showed that he had the habit of biting his nails down into the skin. He demonstrated a poor pincer grasp, weak grip and poor strength. He was unable to lift a plastic chair to move it closer to the table. Keith’s mother said that he was unable to don shoes or socks or dress himself, and showed little initiative for play or social interactions.

When asked to jump on the trampoline, he sat in the middle and mumbled, “I can’t”. He was encouraged to try, and jumped 1” high, 10 times. Clinical observations showed that he had poor tone overall, poor strength, good reflexes, and poor coordination. An informal handwriting test showed poorly formed poorly spaced letters. The Sensory Profile indicated a definite difference from peers in the areas of auditory and vestibular processing.

Keith’s first sessions were child-directed and sensory-based as a way of providing motivation. Within 2-3 sessions, Interactive Metronome (IM) was introduced. He was unable to identify a beat, and so hand-over-hand and patty cake methods were used exclusively for 4-6 sessions, and as-needed, thereafter. Keith was allowed to sit on a therapy ball. Although he bounced on the ball while clapping, making the task harder, it provided him with stimulation and he was better able to attend to the rhythms. Keith received IM 1-2 times per week for approximately 3 months mixed-in with sensory integration (primarily vestibular and proprioception) and ADL interventions.

Keith’s progress was dramatic. Within a few weeks, his mother told me, “The boy who came in here for the evaluation 2 months ago no longer exists.” Her son now begged her to go to the park to play. He attempted social interactions. He was attempting to dress, bathe and groom himself. During the fourth month of therapy, IM was still incorporated into therapy. Keith performed 200-500 repetitions prior to ADL and handwriting interventions to increase motivation for those tasks. He made tremendous progress with initiative, ADLs, sensory processing, social skills and confidence. Keith developed a good pincer grasp and was able to fully dress himself including buttoning a dress shirt. He still had difficulty with tying shoes. He had made very good progress in bathing and grooming, in that he could perform the tasks, but sometimes did an incomplete job. Keith’s sensory motor skills were noticeably improved. He gained an intuitive sense of what his body seemed to need and requested suitable activities both in the gym and at home. Often, those activities included vestibular and proprioceptive components and so he was learning to satisfy his sensory input needs, as well. The activity and play made him stronger, and his grip improved so that he could help move equipment in the gym. His confidence improved to the degree that he was able to initiate social interaction with other children in the clinic, and he relished playing with them.

IM + Core:Tx Interventions

Mark is a 12 year old boy with high functioning autism who returned to occupational therapy after a break of several years. Although Mark was doing well in school, he was unable to fully dress himself or bathe himself. In terms of neuromuscular control, Mark had poor overall tone, poor postural control, and significant motor planning issues. He walked with a very wide gait (total deviation of 80 degrees), had poor handwriting, and lacked the ability to plan and execute movements with his arms and hands that would allow him to reach the top of his head and flex his fingers to wash his hair. In addition, he chewed his food in the front of his mouth and for this reason preferred a soft foods diet. Mark’s social skills were quite limited. He rarely looked at others while speaking and limited his conversations to single words.

Given the range of problems Mark faced, it was decided that a course of Interactive Metronome (IM) would reduce the time in therapy. Mark did IM twice per week for 30 minute sessions. He started each session with a few minutes in the ball pit to help him relax and self-organize. He then did 10 minutes of IM, took a short break on a swing or trampoline and then a final 10 minutes of IM. As his skills improved (and he moved to phase 4 of the IM program), he did 20 minutes of IM and then practiced dressing skills or handwriting.

Progress with IM
The program of IM had profound effects on Mark. He developed a self-awareness and motivation that led to greater independence. First, he figured out how to regulate the shower temperature. Next, he tried to wash his hair on his own, although he still lacked the correct motor-planning for that task. He took an interest in outside activities and began to talk about what he did. He displayed a good sense of humor. He saw gains in motor planning and postural control. He learned to dress himself entirely with the exception of buttoning pants at the waist and tying shoes. He learned to chew with his whole mouth. His wide stance improved, so that his feet were better aligned by 5-10 degrees.

After 19,000 repetitions, therapy took a new direction. It was time for Mark to learn a variety of new skills through exercise and repetition. Mark was aware and motivated, but with his new sense of humor, he was also very playful. It was difficult to keep him on task to perform the more difficult work of exercising his body to make additional gains. For example, when asked to lay over a therapy ball to work on posture, he would fall off the ball and roll on the floor and giggle. When asked to pretend to wash his hair by moving his hands together on top of his head, he would pat the sides of his head with extended fingers, as if to say, “there, all done.”

Core:Tx proved to be the solution for getting him to perform exercises correctly. Its game-like nature engaged him, and he paid attention to the instructions rather than acting-out with silly behaviors. On the first day he performed scaption (shoulder/rotator cuff) exercises. As he attempted to keep Core:Tx’s red ball within the square, he made smooth movements with his arms to the top of his head, using full range of motion, for the first time. He was proud of himself and after two sessions, he developed the motor planning to successfully wash his hair independently. He currently uses Core:Tx in both physical therapy and occupational therapy to address postural control, lower extremity motor planning and gait issues.

Muscle tone and Autism

I have a bunch of 11-12 year old boys with poor tone and goofy attitudes. How in the world do I get them to focus on doing exercises to help firm up muscles? They need those firm muscles for simple functional activities like lifting arms to wash their hair.

A new product showed up in my office a few months ago called Core:Tx. It's a computer-game based exrecise program with a strap-on wireless sensor that detects movement. The "player" has to perform an exercise (like leg squats) and match the speed and range shown on the computer monitor. The game encourages smooth movement along a full range of motion. It's cute, and it catches the attention of a 12 year old boy.

That said, using Core:Tx with a boy with autism is a daunting prospect. It's hard enough to engage children with autism without the additional burden of strapping on a monitor, teaching a "game", demonstrating exercises and getting compliance. As it turns out, I had recently done a program of Interactive Metronome (IM) with one particular lad, and so he was ripe to try this. IM alone did not give him the functional gains he needed. Core:Tx was just the right level of work and play to pull off a successful intervention. And it worked very quickly, too. I'm very pleased with the results. See the next entry for the story.