The case Tracy promised last episode, told in full: an 18-year-old autistic woman who had not leaned over, washed her hair tipped back, or gone down open stairs in over a decade. No behaviour program had touched it, because it was never behaviour, it was gravitational insecurity. Over four months of vestibular treatment built on safety, breath and her feet on the ground, the script flipped, and the world opened up, she now loves Disney cruises. A masterclass in pairing modulation and discrimination through relationship.
We pick straight up from Episode 16 with the young woman Tracy treated, diagnosed with autism, minimally verbal, devoted to all things Disney, and so rigid in her posture she had not leaned over to pick anything off the floor since she was seven or eight. Years of resources had focused on engagement and communication, and a physical therapist had been working on fluidity with Adele and a treadmill, but nobody had asked the underlying why. Tracy did, and recognised gravitational insecurity: at the top of an open staircase the woman froze, as if stepping into unbounded space, and any movement of her head out of upright brought a fear response, held breath, a trapped look. Tracy’s first move was not technique, it was being received and understood, and noticing the woman’s own regulation, a shudder breath as her feet landed on solid ground.
From there the treatment is a thing of beauty. On a platform swing, feet planted, Tracy displaced her the slightest amount until it felt a little uh-oh, then helped her land it in her feet and her breath, pairing tiny proprioceptive shifts, hands from pronation to neutral on a pool noodle, to the movement, so the vestibular-postural mechanism began working in synchrony. They built anchor activities, yoga, Adele dance parties, the swing, and worked the sequence of head, postural and eye movements the way the Astronaut Training protocol unfolds, without running the protocol, always pairing vestibular discrimination with modulation. About three months in, her gait on the stairs changed, she found rotation and feed-forward control, the sense that lets you anticipate your own movement rather than have everything happen to you. The conversation widens into the vestibular system’s role in body schema, muscle tone (the vestibulospinal pathway and the reticular activating system), and a lovely reflection on the art of clinical practice: hold all the theory, then meet the person where they are, set up safety and agency, and notice-and-respond, moment by moment.
Lightly edited for readability. Speaker labels and chapter markers match the published episode.
Cory: We have a wonderful topic for today. Last episode we finished by mentioning a young woman Tracy was working with, who she had done a really comprehensive treatment program with, and it had allowed all of this amazing function to come about. So we really want to jump straight back on that and discuss it more, and hopefully open up the conversation to more vestibular-based questions, ideas, principles and treatment. Hello, Tracy, and hello Michelle. Can you give us a little refresher on that young woman, a general idea of her, what happened, and then we can ask you more about how you went with treatment?
Tracy: Great to be here with you guys. Last episode we were talking about postural development and a lot of concepts, and we converged around vestibular functioning and processing and the many ways it impacts you. All of us have different cases that just live with us, even many years later, because we learn so much from them. This young woman was referred to me through a community resource, someone who knew this family had been struggling, and also from her physical therapist. She was diagnosed with autism when she was a very little girl, and when she came to see me she was about 17. She is very minimally verbal, highly interested in all things Walt Disney, and pretty aloof to most social interaction. She lives with her parents, who were older when they had her, her mom was nearly 50 when she was born. They had always had her in a centre-based school program with a lot of supports, but most of them focused on engagement, communication and socialisation as the primary focuses. What was interesting was that she was so rigid in her posture, this had been described for years, always really fixed and rigid, she would walk with very little rotation, which was why she was in physical therapy, because she just looked uncomfortable in her own body. The PT was a dear colleague I had known for years, and when this woman was referred to me, the PT came to the first sessions and would hit herself on the head, why didn’t I think to refer her to you years ago, because it was so evident this was based in vestibular function, but everybody was seeing it as the surface of the behaviour. The PT had been working on fluidity, grace and ease, mostly playing music, because this woman loves music, Adele was a favourite back then, putting Adele on and having her on a treadmill, varying the speed, working on repetitive movement patterns with a bit more bilaterality, holding a pool noodle the PT would move in a rhythm. She had been doing this for a couple of years, and it was not really helping her generalise. But the primary reason she came to me was that the caseworker helping with adult transition planning asked the parents what would be helpful, and they brought up a whole list that primarily came down to this: she would never bend over. She would never lean over to pick up her shoes. Even getting dressed, pulling her pants up, she was so avoidant of bending, and of moving her head out of upright for hair washing. Those restrictions had been noted by the parents for more than a decade, but nobody had worked on it from an underlying why, because she had been in a behaviour-based program, and everyone saw it as, let’s just work on her behaviour.
Tracy: In our clinic we had a large warehouse-like gym, and from the offices into the gym there was a set of four stairs, open on the right-hand side with a metal railing, opening into this open space. I have a really distinct memory of bringing her in for the first time. She got to the top of the stairs and froze, she could not take that first step, because to her it almost looked like she was going into unbounded space. So I created a barrier with my own body to assist her. Her freeze response would trigger lots of repetitive motion, holding of her breath, feeling trapped and scared, and she would look trapped and scared. Any movement of her head out of upright brought that same fear response. Her system just had not found gravitational security in any way, and she was so afraid, and yet so brave and wanting to figure out what to do. In that treatment space we had a loft against the far wall with a darkness to the shading, and she was interested in it and wanted to explore, so there was motivation, she was tuned into her environment and wanted to move and explore. I am pretty familiar with the theory of vestibular-based processing and gravitational insecurity.
Cory: That might be an understatement, you are so humble. You have read a book or two.
Tracy: What is interesting is that her and her family being received by me, someone who could understand them on a different level, was, I think, the first step in the treatment. Isn’t that interesting?
Cory: I agree. I had that feeling listening to your recount, oh, somebody got it. I could take a breath and let go of the tension of her whole life probably being encouraged to do something when there were lower processing things getting in the way. I am so glad they found you.
Tracy: To this day I will see this woman in the community, and she always wants to touch my face and rub my arm and come be with me, because she knows it was an essential thing that happened in her life. As we went down the stairs the first time, I have this felt memory of her getting to the bottom and doing a shudder breath as we landed, paired to her feet landing on a surface she could trust. That was what I knew to be her own regulation of her gravitational insecurity, because she showed it to me.
Tracy: So we went into the gym and I used a platform swing, because she could understand it as a chair, she would sit on it, and we played with that process she had shown me: let’s sit and move until it feels a little uh-oh, and then in the uh-oh, let’s land that in our feet and our breath. We played with that relationally, and she got really playful with me pretty fast, exploring it and understanding that when she started to get scared, it was not something to overwhelm her but something to land and ground and release. Then we added music ambiently in the space, because I wanted to stay more in connection with her than headphones might allow, but I did use modulated music Therapeutic Listening, because we did not really have Quickshifts then through the Therapeutic Listening, Vital Links method. So I played an ambient sound and started her on a modulated music Therapeutic Listening sequence. We did a therapy intensive over several months where she came in a couple of times a week, and I would work with her and show her mom. They were also transitioning a person in her life from nanny to friend and provider, who all these years later still lives with her, so mom or this woman, or both, would come to sessions, and the PT came intermittently. We started to work on how to help her feel her rotational movement patterns, finding rotation in upright, because her head was not ready to move out of upright, someone behind me, someone in front of me, and being able to recover from the disruption that happened so rapidly as soon as she moved her head too much. The vestibular system wants to find movement and its centring points, so whenever you work with kids you work on both: here is your landing ground, your referent point, now let’s move off it and see what happens, and come back. It took several weeks before we could move out of upright. How we did that was that she had been watching the nanny do some yoga and was interested, so we figured out how to get down on the mat. At first she would collapse, and it took a lot, so we worked on the mat rolling, side to side, with games and silly sounds and Adele parties, which were very fun. Then she could start to do transitional movements through this, let’s try yoga, let’s have an Adele dance party, let’s move on the swing, and those became our anchor activities. From there we moved into the sequence of head movements, postural movements and eye movements, coupling those across different sequences, all the time making sure she knew she could come back to grounding and safety, because the modulation disruption was so real it trapped her ability to use the system to get any discriminative detail. So we were moving between vestibular discrimination and modulation continually.
Tracy: We moved through the sequence the way you would in the Astronaut Training protocol, but not doing the protocol, really thinking about the way it unfolds, and giving her the movement opportunities she enjoyed to do every day at home, with the Therapeutic Listening as a background beat of support. The biggest shift I noticed was maybe three months later. We went to go up the stairs back into the lobby, and her gait changed, she found she could step and then step, instead of putting two feet on each step. The freedom of rotation in her postural system that allowed that, she realised it and started to play with going up and down the stairs on her own, which was huge, because gravitational security allowed her to move into that higher-level postural work, and she needed both, you cannot treat one without the other, they have to be paired. Once she found that freedom of movement, it got a lot easier, we could do more yoga poses and use different swings, because she had found that base of security. Her favourite activity now is to help her helper plan Disney cruises, and she loves being on a boat, which I think is the coolest thing ever.
Cory: There is so much in what you just said, all the complexity.
Michelle: But also the patience, because Tracy has a textbook in her brain about vestibular development and neurodevelopment, and yet your observations started before any formal clinical assessments. You were noticing the impact on function, that it was discrimination and modulation together, and that you could not even proceed with a vestibular program as such and move through typical neurodevelopment, flexion, extension, nodding of the head. First you needed to ground her feet, address that safety and connection issue, help her feel embodied safety, and let her sense you were not going to push her too fast or too slow, that she could find it for herself, bringing in the things that bring her joy. You just cannot start there. I love the patience and skill that took, Trace.
Tracy: I have to thank Adele for the song Hello, because it was one of the activities, we could have someone be behind her and say, hello, and then she would want to look. It became part of the treatment.
Cory: The other thing that struck me strongly is that there was clearly containment of safety in you and not pushing her too far, so the relationship was underneath everything. And it hit me, the difference between discrimination and modulation. There was a massive modulation piece right in front of you, she was terrified, that is the biggest modulation cue ever, I cannot tolerate this, it is too much for my system, I cannot stay regulated. But you wove in the discrimination piece together, through the relationship and the just-rightness of what you were doing, my body’s moving, my body’s stopped, regulate, the moving piece is discrimination, but I have to modulate. You were doing that precisely through the discriminative system, in a stepwise way, starting in upright, helping her discriminate her head in space facing forward, then turning away from forward and coming back and regulating, all through relationship, step-wising it through all the ways you understand the vestibular system. And what you got was this unfolding of function without pushing, you put in the pieces she needed and suddenly she could engage in her life in a different way.
Tracy: So true. The vestibular system is also so essential to our sense of body schema, part of which is our relationship to gravity. She had almost cut out any awareness of what was happening below her shoulders. She did not look down, did not reach down, did not relate to the rest of her body well, so she would almost look like a visually impaired person sometimes, the way she walked, the way adults navigated the world with her, as if she was missing the whole lower visual field, because she did not really regard it. The thought that there is something down there that could be interesting to me was the farthest thing from her lived reality, until it was not. It is amazing when you lift that veil of security. Gravitational insecurity in Dr Ayres’ frame is sometimes talked about more as a vestibular discrimination issue, but you have to be careful to tease out which place it is coming from, and for her it was a bit of both.
Michelle: Trace, I had questions about what you noticed and some of the first movements you got her to make on the platform swing. I am assuming the steps went down, so part of her stopping at the top was that she could not flex her head to orient her eyes down below the horizontal to see the steps went down, that in her periphery she just saw a nothingness. My other assumption was that it had a spatial quality, that without that right-sidedness, before you became the rail down, there was a lack of a thing to orient her to the vertical. Were the steps down, and was it the flexion of the head that was problematic?
Tracy: Absolutely. Anything downward space she had sort of cut off, and she had really almost lost any freedom of flexion and extension. Even in her gestures she did not use a yes-or-no head shake, she was so rigid and held. The lack of being able to freely take in the space around her and use that normal mechanism of eye gaze, head movement, head on posture, none of it was secure for her. It was pretty profound.
Michelle: I know it just evolves and you make the best choices, but you mentioned she was gaining stability through her feet, that that was regulating for her, so you offered that in the platform swing. With the platform swing there are usually vertical ropes that can provide a spatial thing, so I am guessing she was hanging onto those. I would have wondered about getting her to move in flexion and extension through the head on body first. You mentioned her turning around in backwards space, did you go to backwards space first, or was that just in your recap?
Tracy: That was more in the recount. First it was a flexion-extension pattern, and really just her whole body moving as a single unit, sitting on the platform like a statue almost. She would move forward and come back, and I would help her find the ground again, repeating that shudder, I’m here, I’m here, we’re here together, because that was connecting for her, she knew I had noticed it with her, we had shared that moment, and she knew I was going to hold it with her, stable. We did that a lot, just sitting, and within that I started to help her find her power through her upper trunk and arms, when I pull, what happens, when I push, what happens. She was familiar with a pull, push or side to side from the PT’s work with the pool noodle, so I used that as a referent point, a pool noodle to hold with both hands in pronation, then we would put her hands in neutral. If you do that yourself while listening, put your hands out in pronation, then go to neutral, feel what it does to your upper trunk, how it changes your breath pattern and alignment, you get into capital flexion with a little internal rotation of the upper extremity, and then you can go into extension. So we played with that just through her hand position, rather than me forcing it, giving her an opportunity through biomechanics to feel the postural shifts, then pairing those shifts to the movement and the rhythm, so the vestibular-postural mechanism starts to work in synchrony, because I am putting the synchrony in. She did not arrive with synchrony, so I had to help her find it.
Cory: Let me pull that apart. Initially she is on the platform swing, sitting, feet planted on the ground given her gravitational insecurity, and you were displacing the swing slightly, just the slightest. When you stand on a surface that shifts forward, you get this lag of the body, your feet move and your body lags back for a second, then catches up with your postural mechanism adjusting. So just that level of displacement was enough to create an arousal shift, which you helped her organise by stopping, finding breath, and helping her recentre. Is that right?
Tracy: That is exactly right.
Cory: And then you tried to pair the proprioceptive cues from her arms and shoulder girdle by helping her hold on but change her hand position, hands holding something, palms facing down, then helping her rotate, which created proprioceptive cues. I am guessing that helped her find some head movement that was modulated by the proprioceptive cues in her hands, and that she was doing it for herself.
Tracy: I think that is true, landing it into her posture, here I am, I’m grounded, I just did that, my head moved, and I’m okay, here I am. But here is another really interesting thing. Dr Ayres talked about this all the way back in the early 1970s, and we need to talk about it a lot more.
Tracy: This is a real neurological phenomenon of the vestibular apparatus: when we have vestibular integration, it gives us the information we need through the sensory-motor system to have feed-forward control. Postural and gravitational insecurity is almost a lack of feed-forward, everything happens to you. So in moving her head and landing her body and feeling minor little baby postural adjustments, it was like the script finally got flipped, and she could feed forward what was going to happen when she moved. That was vestibularly mediated, and the crux of the whole formula.
Cory: So if you do not have good quality information from your vestibular apparatus to signal my head’s moving or not moving, then I cannot predict, I will get frightened if you displace me, because I cannot anticipate that feeling or integrate it in my nervous system.
Michelle: And my body does not compensate for it. I have to do something to stop that happening, because if the vestibular system is not activating the postural muscles to turn on and stabilise, she is at the whim of a body not moving or moving. Trace, that is so brilliant. It is tempting to put them on a swing and give them a little ride, particularly with younger kids where it is more age-appropriate to be on the swings, it is tempting to miss these bits where you start providing vestibular input just to their body. She was sitting on a swing, but it feels like she got more input than she might typically allow, through some pretty minor movement, and even in that pronation-supination shift, what that lifted the body and thumped back down, she learnt she had a mastery over it. Rather than the passivity of just being on a swing anticipating what’s coming, you took that away by making it body-based first.
Cory: If you were watching and knew nothing about the vestibular system, or OT or sensory integration or Dr Ayres, and you came in and all you saw was Tracy sitting in front of this young woman on a swing, moving her slightly and then going, ah, you would be so confused, what is this person doing? But I find that even when parents can tell, what is going on, what is Cory doing, somehow they feel and see the magic of that child coming alive. And you would have been able to explain the why at some point, so they could come to understand the process with you.
Tracy: So true. If you want to read more and go into the neuro, you can read whole books on it, but if you read page 57 in the Sensory Integration and Learning Disorders book, the last two paragraphs and onto page 58, it tells you exactly what I did and why and what the neuroscience is, and that book was published a long time ago.
Cory: The challenge is that book is not in print anymore. Do you know how many hundreds of dollars these books are?
Michelle: I have got it in its own little vault. I have 57 and 58 tagged. My question, when I revisited her brilliant book, is that I had missed in my reading the potential impact of vestibular function on whole-body muscle tone. I was so focused on function and moving through developmental capacities, flexion, extension, weight shifts, rotation, that I missed that Ayres says the vestibular system has a strong influence on muscle tone, both generally and more specifically through certain neuromuscular reflexes. I had missed that it can impact all of muscle tone, a readiness for action, where I thought it was specifically down the spine, cervical, thoracic, lumbar. Ayres also talks about the lower-tone, clumsy kids in terms of learning disorders in this book. So is that because the vestibular system was not processing well, either at the receptor or through the neural networks landing at multiple sites, contributing to overall low body muscle tone?
Tracy: The vestibulospinal pathway is a really particular pathway that activates postural muscle tone. We think about linear activation, or a rotation off the midline, any of those can activate vestibulospinal processing. But even just moving your eyes up and down does the same thing, even just moving your wrists into pronation or neutral rotation, because of the way the body proprioceptors and the vestibular apparatus interact, especially around head, neck and eye movement. So some of it is the vestibular input itself, and some is the way the vestibular system supports the postural system. For her, she had restricted all of that, the vestibular movement was not even available to her, so we had to go back and treat through both, she needed enriched, careful vestibular experiences, but paired into the adaptive sensory-motor system that is our posture.
Cory: I have a question about muscle tone that relates to last week, state and the postural system. Is Dr Ayres referencing the fact that the vestibular system feeds into the reticular activating nuclei in the brainstem, so as we stimulate the vestibular pathways, of which there are many, we are influencing arousal states pretty quickly into that reticular activating pathway, and if I increase your arousal through that system, I am going to increase tone in the whole body. Is that where she is getting at?
Tracy: That is it.
Michelle: And that is a readiness, movement’s coming, body get ready, the postural muscles but also everything else you might need to respond.
Tracy: That is it, Michelle.
Michelle: Tracy, I love thinking about the process you worked through. It strikes me every time that we move from learning very explicitly about a thing, the vestibular system, the neurodevelopmental sequence, the equipment, what helps flexion come about, into wanting to test it out in the clinic, what can I do with the flexion swing, what will bring on weight shifting. What you have reminded me of exquisitely is that the art of what we do is to have all of that information in your brain, but to meet that woman where she was at. You did observations, maybe not even a formal clinical observation assessment, took some information, and it gave you what was working well and some cues about what was not. You started with safety, the threat valence we talk about, then set up a situation where she felt safe and had some agency over what was going to happen to her, really attuning to her body and to things of interest to her, Adele, for example. You met her there, supported her to feel safety, and were trustworthy, the room was trustworthy, the swing was an opportunity she could explore in her own way. You allowed her to explore safety, threat and regulation in her own body before you took it into equipment, and that was a real moment-by-moment attuning and making clinical decisions about what to do next. There was a suspension, an allowing of what is going to unfold, and how she met you informed your next moment. We can go in with a treatment plan and a bank of knowledge, but then we just have to notice and respond, keeping those principles of regulation, connection and the just-right challenge.
Cory: What you were saying made me think, as a therapist, it is the not knowing what you are going to do that feels hard, especially when you have been treating a child a few sessions and think, what are we going to do this session, you feel you need a plan of some form. But I think about what Tracy did, and the reason she could do it is that she has studied the system to the nth degree. We are not all going to know it to that depth, but she drove and motivated me to go and understand how the system works. There is a big gap between learning the neurology of the vestibular system and knowing how to treat it, and that gap is where it feels scary. But in the process of learning more and more about how the vestibular system supports different functions, the eyes, the postural system, the shifting of arousal, how it integrates with the other sensory systems, that has let me understand in treatment what crawling on the ground does, or when I am wrestling with a child, how much to shift them off and how much to bring them back. If I am not attuned and they want to wrestle and we go too far, and they are compromised in their body schema and ability to tolerate movement, I will not understand where I triggered them off or why. Now I can understand, you find upright pretty easy, and if I just shift you this much, I am activating the vestibular system and watching, did the postural system make an adjustment or not? If it did, great, I have given just enough to create the adaptation. If it did not, and you lost me or fled or got angry, I can understand how to adjust for next time. So it is hard to learn, but the more you understand how the vestibular system impacts function and links with the other systems, the more you can let go of the steps and embed vestibular opportunities into the games the child is interested in, in a fun way. Tracy did not just get her on the swing and take her for a ride, she understood the principles, where the woman found safety, and maintained relationship while challenging all of those pieces and helping her move to the next level of adaptation. So thank you so much, Tracy, for sharing.
Tracy: Listening to both of you summarise was lovely and powerful. We love talking to each other about this stuff, and I never want the conversation to end, because there is depth and depth and depth to it. It is so interesting and fun, and I thank you.
And that’s a wrap on today’s episode of Spirited Conversations. We hope this sparks something for you, whether it’s a new clinical idea, a fresh perspective, or just the reminder that you are definitely not alone in this work. If this conversation resonated, we would love for you to share it with anyone on their own learning journey. You can find information about the podcast on our website, and you can join us in the courses and communities the Developmental FX team have put together at developmentalfx.org. And if you’re enjoying listening, please subscribe or leave a review, it genuinely helps more people find us. Until next time, keep the conversations spirited!