2. Why Posture Matters

Feel free to download the postural diagram below for reference throughout this episode.

TRANSCRIPT:

Cory: Hello! welcome, it's episode 2. Hi Tracy how are you?

Tracy: I'm great! How are you guys down there?

Cory: Yeah good, you Michelle?

Michelle:: Yeah I'm ready to go, excited.

Cory: I am too. So today I have brought a composite case that I think will be really really helpful for everybody. Particularly because at the end of our last episode we were talking about, we sort of eluded to postural functions and I assessed this little kiddo not that long ago and I thought - you're perfect! So this is a 12 year old boy and he came in to the clinic to get assessed for handwriting challenges. Really having difficulty with legibility, not able to get his ideas out onto paper and they basically wanted supports for school and to know how they could help him show his best academic potential I guess. So in the clinic I did the 3 beery's - the VMI, visual perceptual test and the motor coordination test. I also did the handwriting print tool which is from the handwriting without tears program and I also did the handwriting speed test. And just because I think it's so helpful to know about the postural system when you're assessing handwriting, I also did the COMPS. So the COMPS is the clinical observations of motor and postural skills and I added in a few extra clinical observations that aren't formally on that assessment but that I think are really helpful for me.

So I know that Tracy I've been to a few of our lectures and you've got really great postural models that I think might help us with talking about this kiddo so should we chat about that?

[00:02:47] Tracy: Yeah let's jump into talking about that. So I think in the show notes we will go ahead and pop up one of these visuals that I find really useful and often use both in training but even in my own clinical work and what I find helpful in clinical reasoning is to have some visual models. So that when you're doing an assessment, when you're treating a child, when you're consulting, when you're just trying to think it through, that you can kind of pause and reflect and organise your thoughts. So visual tools are super helpful to that end and I think throughout the series, all of the different episodes. we'll be sharing visual tools like this because they're really helpful and especially in a podcast forum because we need ot be able to kind of see what we're talking about sometimes, and because this is an auditory mechanism were going to have that visual so I think it's going to anchor us a little bit.

So one of the visual is just this flow chart and it comes to us from the combined models that are really around core development and the model is drawn from a NDT and Neurodevelopmental Treatment perspective, but is also integrated with a Sensory Integrative perspective. Those two interventions are core to what we do in pediatric OT anyway and are really going to underpin those assessments that you did Cory. So when you were testing this little guy, what's interesting is that the tests themselves are kind of measuring either speed of handwriting, or they're measuring a visual motor integration skill or capacity. But all of those things are related to underlying sensory motor functions and we don't always have tests for all of those sensory motor functions. So where clinical reasoning is really critical is helping you to interpret test data, helping you to interpret observation data and then interpret that in a way that leads you to the clarity that you need for a really concise and obvious treatment plan. And also for guiding teachers, school teams and parents. So this gap between data - the data of the testing - and clinical treatment plan, so it's really fascinating that gap.

Michelle:: And I'm just noticing, thinking about it, that what you are measuring is that output. And so what we're going to talk about is the 'inputs' I guess, is that what you're saying Tracy like the underlying inputs that allow, or facilitate or restrict him to handwrite, which is the output.

[00:05:52] Tracy: Absolutely! Which is a great way to think about it and really if you think about sensory integration as the organisation of sensation for use. That's exactly what we are talking about, so on some level Doctor Ayres always wins and she always kind of has the framework that allows us to dive to that level of zooming into the input. The 'what is going on' in the underlying performance components and then how is that restricting that output in the daily life, daily function and daily occupation so here we are talking about the joy and purity and beauty of our profession really. Its the piece that people don't always understand but when we get to it I think it's so juicy and so amazing, so yeah. So in this visual model that we are referring to, the concept is to sort of look at the sensory postural triad and sometimes now we call that now a sensory postural Quadrad. We'll get into talking about why that is now.

Cory: Oooh I've never heard that before

Tracy: You know in the classic neurosciences there is this relationship between the visual, vestibular and proprioceptive processing. And those are the corner stones, in addition to that auditory partner, the quadrad, but those are the corner stones of postural adaptation. So as you go to do an assessment and you notice that this 12 year old was struggling with fine motor control, but then there were probably some really interesting findings throughout the postural system and you looked at clinical observations that included balance, and reflex integration and anti gravity control. So tell us a little bit more about those findings and we will use this visual to start to organise our thoughts around that.

[00:07:51] Cory: Okay that sounds good. So um, even in, I will definitely talk about his performance in the clinical observations in each of those tasks but even in the Beery, while he was copying the shapes or doing the fine motor control there was a lot of shifting of body weight. So anytime he had to draw, he was using his right hand, and any time he had to draw on the left side of the paper he would shift his whole body to the side to draw the shape or he would turn. And so immediately I'm thinking about his midline and how organised he is in that space and whether he is efficiently able to cross his midline without any trouble, but the fascinating thing was that he asked me "do I have to hold the paper with my other hand". So that was really funny because I was like "Oh you don't have to..."

Michelle:: "What else are you going to do with it though?"

Cory: Yeah haha. "Do it if you want to". So something that should be super automatic he's obviously been taught to do, or knows that it's something he should do but he was kind of propping himself up with that arm, so he was like so I have to hold that page with my other hand.

Michelle:: haha "because I really want to hold myself up"

Cory: Yeah, yes! And that was so funny to me and I just said "well you know, whatever works for you" And so that was very interesting just in that observation in itself. So then when I came to do the handwriting speed test, there was a lot of postural fatigue. So what I mean by that is resting his head on his arm, stopping what I'm doing, even though it's a timed test - it's a three minute test to write as many words as you can, as neatly as you can - and he's stopping to shake his hand out and he's leaning on his hand and it didn't seem as though there was an urgency to what he was doing.

And then if I looked at what he was writing, as he progressed through the test, the legibility just went wayy down. He just got more and more tired and everything just kind of went out the window.

Michelle: His accuracy just went out the window?

Cory: Yeah

Michelle:: Did the size get bigger?

Cory: Yep, the size got bigger, even spacing between words, it was hard sometimes to see where he'd ended one word and started the next. And that test isn't necessarily about legibility it's purely just about speed but it gave me a good indication. You know, if you are struggling with three minutes of writing it's going to look I'm sure, pretty terrible if you have to do a whole writing task at school.

Tracy: Absolutely.

Cory: Yeah right, yeah so any test where he's going to have to write a decent amount of writing is going to be, I'm sure, really fatiguing and then potentially he's not going to be able to get the marks because you can't read what he's writing.

[00:11:10] Tracy: That's exactly right. So when you think about handwriting drifting and sort of that struggle that happens pretty quickly and you also noticed background postural difficulties right away, it is going to be really critical for this little one to have those postural functions better understood and really addressed directly in intervention. Because you aren't going to be able to build enough strength and enough work tolerance and enough skilfulness to sustain beyond a few minutes without the background postural system being able to automatically subserve the control and stability function and just maintain that for long periods of time. So by the time a child is 12 years old we would really expect that they would have an ability to write for long periods of time. 30-40 mins without a suepr amount of fatigue and so this person is at about 10% in terms of that fatigue quality. So we want to really back up and understand what's happening in that postural system. And you mentioned a couple of things about how midline orientation, crossing the midline were really obvious. And sometimes the functions that are at the higher end of this visual chart that we are referring too, they're often really glaring and obvious to see. So you'll see that on the left hand side of the chart, midline stability is kind of hanging out up at the top. And it's a pretty obvious skill, so when kids are struggling with midline function, it's not obvious to maybe everybody but for occupational therapists I think inparticular, we're pretty tuned into looking for that. And we see it and it becomes fairly obvious.

[00:13:26] Michelle:: And it's fascinating to me that in the task, and it sounds like not many minutes in that he was doing it, he was already looking for strategies to accomodate for that, so whether he sat at the desk for 10 minutes only, and was about to do a 3 minute task. He was working it - he was like "Oh can I put my hand here" because I'm already exhausted..

Cory: Before he even started

Michelle:: Before he even starts but he's got some strategies to work around it. His postural stability and midline challenges I guess.

Cory: Yeah and I think as well, like you said, before you even start you can almost get a sense of what their postural system looks like by the way that they sit in the chair and just I guess the effort! The effort that you can see them putting into the task. And sometimes you'll - I can't 100% remember but sometimes you'll see that mouth kind of...that tongue sticking out and jaw opening and all of that sort of stuff to help me get my hands to work and do this activity and then you just think - wow, how hard it would be for you being 12, in class and then working all day and you can't even sit here and do these not super difficult activities for 10 minutes and you're really working hard.

Michelle:: And he's eager to comply to he's trying to do his best but it's like "oh I just need to put my hand here".

Cory: Yeah! And so sweet he's like "do I have to put my hand there?" You know he's like asking!

[00:15:04] Tracy: Yeah! And how wonderful because we know that, that isn't necessarily how every child copes is through being sweet and cooperative. And especially when basic things like antigravity control - finding my stability upright against gravity and being able to maintain that for long period of time. When thats really hard or you, and fatigue comes over you it's quite common for kids like that to start to feel a little bit low and slow about the world, about their own selves about relationships sometimes. And so the fact that this 12 year old is finding a robust empathy, and kindness, self compassion, kindness to himself. That's really really cool and I love that but it doesn't help him at all in terms of his postural control.

MUSIC BREAK

Tracy: So when we think about midline issues, and then you start to look underneath that you talk a bit how he was kind of tipping off midline, you know not finding alignment in his midline. And sometimes we call that vertical righting it's this upright, middle, antigravity control position. And he kind of slumps over and leans. Sometimes kids do that because of low muscle tone, sometimes they do that because their sense of their midline -their somatosensory and vestibular sense of their midline is off, sometimes they do it because of just fatigue and endurance and strength issues and that can be related to the first one I mentioned the low muscle tone issue. But then they sometimes also do it because every time you start to move off of your midline it pulls for basic sensory motor patterns. And sometimes what happens is that you are 'stronger' in a way, if you use a fixing in a pattern instead of just having the esae and fluidty o fjust maintaining the upright postures. So there can be all kinds of things lurking underneath the description you've given us so far and Im really curious to hear about some of the assessments the clinical observations you did and kind of what that will hep up to understand in terms of these pieces that are lower down in this visual chart.

[00:17:49] Cory: Yeah sure! So I did the standard prone extension, I might just list out what i did and then I can go through some of the observations for you. So i did prone extension, supine flexion, rapid forearm rotation, I did finger nose touching - the one where you hve one hand out in front and then your finger coming from your nose to your hand in front of your face. I did ATNR, umm there's one other in the COMPS that I did..Oh I did the slow movements and then I also did some extra things, the classic standing on one leg, ocular tracking so smooth pursuits and saccadic eye movements, I did a tonic lab test and I think I did a few others but..

Michelle:: Any movement? Like I'm interested in how he moves so catching a ball, kicking a ball?

Cory: I didn't do any catching or kicking a ball, I did some rolling umm but other than that I didn't do a whole tonne of movement I just did the standard clin obs but it struck me that, well one of the biggest obvious issues that I saw that I was like WOW, that's really not pulled together for a 12 year old was his ocular tracking. I mean his prone extension and supine flexion were really poor quality, in that when he lay on his stomach and tried to lift up he found it really hard, he found it really hard to get his legs, his chest, his head and arms off the ground. He couldn't sustain it and he said "wow that was really hard" after he'd done it. And I was like "yeah I can see that's really tricky for you". And then the same when he was on his back, when he went up into that supine flexion position, first of all he couldn't do it as one movement - so he had to lift his legs and then his arms, he just couldn't do it all as one. And then his quality of chin tuck and actual flexion was not very, it wasn't really great. He didn't look really flexed in that position. And i asked him which one was harder, which one was more difficult? and he said the prone extension he said "that was really hard!" and so I said "okay haha, no worries". And curious when I tested his tracking, just purely smooth pursuits in the horizontal plane, he had some massive jumps, like really big jumps of his eyes away from the object that he was tracking at midline. I hadn't seen that for awhile, usually I will see some flickering or some "oh what happened there, I lost the target and then I brought my eyes back on" but he really, his eyes really jumped away from the target. And I asked him "how to do you go with reading? Do you ever feel like you skip words or you miss things?" And he said "Oh yeah I have to re-read things a lot of times sometimes to actually read it properly". And it didn't surprise me at all, the same with the saccadic eye movements his eyes would over shoot the mark. He frowned and squinted and his eyes were watering and he was really working hard. And I said "oh this is really hard, we won't do too many more". Cause I know I don't like doing that test cause I know I find it a little hard myself so I really feel for kids when they're working so hard at it and I just know how uncomfortable it can feel.

Michelle:: Oh and everything work really hard! It sounded like you didn't land on anything or that you're describing, so it's the cumulative effect of "ohh what are you doing to me" haha.

[00:21:46] Cory: Yeah right! haha I did really feel for him because I was like you are working really hard for me right now and I appreciate how hard you're working and you're not putting up a fight right. So um, the other fascinating thing was when I did his tonic labyrinthine reflex test, where I had him stand with his feet together and stand with his hands by his side and got him to close his eyes and slowly tipped his head back in space and just asked him to hold that position. He looked, really, really uncomfortable. So his eyes started fluttering, he was swallowing, his cheeks got flushed. And I thought he was going to fall over and so I grabbed onto him so he didn't fall and he flinched like really badly. And I said "oh I'm so sorry, I thought you were going to fall so I just sorted wanted to catch you so you didn't fall over" but yeah so I guess I came away thinking even potentially a tactile processing issue, I mean I don't know if that's there as well or if that was just - I got a fright because my eyes were closed and I didn't know you were going to do that - even though I said I'm going to put my hands here incase

Tracy:Right!

Cory: You know, that was fascinating to me and I thought well that's probably going in with this quadrad that you're talking about around this vestibular processing piece where he's not able ot get up against gravity as well as proprioceptive issues around "where's my body in space and coordinating my body together" and I thought well there could be some tactile issues as well thrown in the mix and there's definitely a visual tracking, an ocular tracking issue. So I don't know does that give you a big more information about how he performed?

[00:23:37] Tracy: Yeah absolutely, yeah there's so many pieces there! So it feels like if we just look at the visual graphic as an organiser you know all the way down the left hand side.. and we can use this chart in up/down, back/forth kinds of thinking...but if you look at the functions that you've described really very specifically on the left hand side. He's really struggling with all of those functions, so his alignment and stability and holding patterns are really weak. He has still retained tonic reflexes, and the tonic reflexes and antigravity control in supine flexion and in prone extension start to be really critical observations to make when you start to have the clustering of difficulties that this little guy or this guy. I keep calling him little but I don't know why I'm picturing him that way, maybe it's just because his nervous system is a little vulnerable and it feel young to me.

Cory: Yeah!

Tracy: And so maybe it just keep pulling me to little... So when you see that level of processing issue. It is going to be very likely that were going to need to look super specifically at the vestibular processing mechanism. So the tonic labyrinth reflex, the actual labyrinth is the vestibuarl labyrinth - that's what you're triggering.

Cory: Yeah right

Tracy: And when you move the head out of alignment, the head neck complex out of alignment, especially when you occlude vision - which is how you kind of standardly do that test (so you don't have the horizon to organise around) and you're tipping the canals and the superior and the inferior semi-circular canals deep inside the deep partners of the vestibular apparatus. They're set up to work in opposition to each other. So when there's a sudden influx of information to the inferior or superior canal as you tip the head through space, what that does is that right away changes the tonic activation of the flexion and extension throughout your whole trunk and it changes it also in your extremities. And so..but really importantly the vesitbular function it organises not just it's response in relation to the head neck complex but it's really around the neck proprioceptors and it's firing off with the neck proprioceptors. So what you saw with the visual flickering is that as the head is moved and the neck proprioceptors are stimulated, that they are trying to recruit that visual partner to say "what is going on out there? Why are we moving? Why are we moving? Because my body is standing still but now my head is moving" So often what you're going to see is that the nervous system does this adaptive response of trying to say "help me out partners, help me out I need, I'm recruiting information". And so the recruitment of information is going to stimulate through the MLF pathway - the medial longitudinal fasiculus the sort of neck, proprioceptor, vestibular complex, that that is going to communicate up to the eye muscles to and it's going to pull on those eye muscles to say "what's going on out there?!" and When you occlude vision, is what you are going to start to see is some level of automatic eye muscle movement, nystagmus we sometimes call that, but it's this kind of response of the eye muscles to trigger and say - give me information, I need you to localise, I need you to find your midline, i need to find stability patterns. And the vestibular system when ever it is moved in the tonic sense, it really asks the whole postural system to find stability. And so when it can't find stability it really becomes an autonomic event. You know its so interesting, because now in our world we have new theories, poly vagal theory in particular, that have really started to come in to help us have a different level of understanding. But Dr. Ayres all the way back in the 1970s wrote a lot about this. Even in the blue Sensory Integration Learning Disorders book, she writes about the tonic labyrinthine, when you see it fire off in the way that you’ve just described, that you’re going to really see it as being an autonomic level of dysregulation. It’s pretty deep and low in the nervous system that you’re seeing disruption from this. So I think that this child is really struggling with a really deep level of vestibular integration problem. And how you’re seeing that show up is in weak postural adaptation and then that’s leading to weak ocular function and then weak handwriting. So it goes all the way through this system - all the way from basic vestibular processing, through the postural adaptation system.

MUSIC BREAK

[00:29:45] Michelle: Wow.

That's got a, such a pervasive effect on him. Tracy, I'm just wanting to go back to the vestib function. So when we do that test, we are tilting the head backwards, slowly. So if the vestibular system is, processing well there should be no need to recruit. So if I'm having Cory tilt my head back, I typically should not need to open my eyes, is that right?

[00:30:17] Tracy: Yeah, once you have integration. So we're, we'll always use the word integration because it's so real. But when you have, in the integration of this function, what happens is that as you tip your head back, you. Make postural adjustments. So you're still feeling the somatic sensory sense of your body and space.

You know, you're connected to the ground, you know you're upright against gravity and so, and you know you're not moving. Because you have integrity in the vestibular, somatic sensory relationship. And so as you tip your head back, what happens is that you're going. Always get a differential firing of the muscle groups that are on the front and backsides of your body. Aand so even in you and I…

[00:31:08] Michelle: that's to acc… sorry, that's to accommodate for that change in, head position, specifically the vestibular system.

[00:31:15] Tracy: Yeah, it is. It's to accommodate for it. And it's partly because your center of gravity is now shifted. So if you're standing steady, so everybody in the, you know, even listening, just stand steady and kind of orient your eyes straight on the head horizon and, and have your nose kind of straight out. And what I want you to do is just take a breath and feel your center of gravity. and wherever that is now, if you just tip your own head back, what you're gonna notice is that your center of gravity is gonna rise.

Maybe two to five inches. Do you notice that?

Cory: Yeah, I do.

Okay. So that's just because what you've done now is you've moved out of a balance in the sagittal plane of the flexion extension muscle groupings, and you have raised the center of gravity. So now you know you're gonna have a differential firing pattern. If we put an EMG on you you would have activation. all the way through the whole muscle, muscle synergy from the tip of your toes to the top of your head. And it's gonna compensate for that change in center of gravity. Center of gravity is where we align. We align around that, and our three four dimensional midlines are all organized around our center of gravity and our base of support.

Yeah. So when the relationship between center of gravity and basis support moves, there has to be a muscle response. Some people over attribute that to the reflexes now taking over. No. The reflex is there to help you. So we all have that tonic labyrinthine reflex, but what happens is that when you can't integrate it, when you can't integrate that, my head tipped back and I can't. Adjust to my now higher center of gravity, the relative muscle activation of the ventral dorsal surfaces being activated. That's gonna make me feel disorganized because I'm used to my center of gravity being lower than that.

[00:33:19] Cory: Oh Right, So he's not. In this, like what we're talking about, there's a potential here that because of the underlying issues around processing the information from the, the labyrinth of the vestibular system, When you tip him, he then loses all of his center of like where he has his center of gravity and where his basis support sits and when you tip him and move his head, if that changes, he then doesn't know. what to do with that information? Is that

[00:33:49] Michelle: He just didn't automatically make adjustments to accommodate for a change

[00:33:54] Cory: Yeah. I was just thinking about the sensation for me, like, so when you were saying everybody listening, you know, put your nose just straight out and then just take a breath and see where you feel, and then tip your head back and see how that changes.

I guess because of the way of our, the way our vestibular system organizes, When each change of center of gravity for ourselves, when we experience changes of center of gravity, if we have integration around the vestibular system, we then know what to do posturaly with each of those changes. Without that, then we don't know what to do with it and we recruit help.

Is that kind of it?

[00:34:30] Tracy: That's precisely it. That's exactly the definition of postural adaptation. And postural adaptation is one of the most. Important automatic functions that stays integrated all day long as everything is moving and constantly changing, and it's the biggest, one of the most primary products of sensory integrative processing.

So postural adaptation in and of itself is an outcome of quality sensory integration, of the real integrity of sensory integration. And when you see a breakdown in postural adaptation like we see in this little one. In this youngster. Then you're gonna really see that that's a reflection of weak sensory integrative functions.

Tracy: So when you go to try to treatment plan for a child like this, um, there are lots of different treatment approach. And what we wanna do is not get stuck on any one of them, but really work toward integration. Yeah. So we are gonna acknowledge that there are difficulties with reflex integration from an Ayres perspective.

You know, you work on reflex integration by using, enhanced vestibular somato-sensory experiences, but in a postural context. And sometimes people miss this. So I love that we get to talk about this today, , because

Michelle: Break it down for us. Tracy. Break it down.

Tracy: Yeah. Yeah. It's just one of those really important parts of the legacy of Dr. Ayers's work that sometimes gets lost, I think. You know, the idea is that you are really on purpose choosing movement activities for the child that puts them in positions that requires them to work in opposition to the reflexes that are kind of disorganizing them or, or looking the most unintegrated.

So for a TLR, Dr. Ayres wrote really specifically that you're gonna work. in prone extension a lot. Yeah. And because this, you know, youngster doesn't have organization of prone extension anyway, we would've chosen that anyway. But we're gonna really wanna use like a scooter board ramp. and get fast linear acceleration to build through the vestibulo-spinal pathway, the quick fire of muscle tone, bring into phasic activation, some anti-gravity control. And then let that vestibular activation help the nervous system drive the muscle control.

The anti-gravity, extensor muscle control. And then once we've got that as kind of a priming, then we're gonna wanna work in active prone extension to build the strength of that tonic activation against gravity. And that becomes almost like formulaic in our treatment. It's Dr. Ayre’s wrote it way back in the late sixties, early seventies, and it remains so consistently true across different treatment approaches that it's really the corner of stone. So that's cool I think, that there's so much clarity about what it is that you would, you would sort of target. Yeah.

[00:38:10] Cory: Right. So, wait, can I just clarify one thing? So I'm just thinking about other kids that I've popped on scooter boards before.

I'm trying to get some of that fast linear input into the vestibular system to fire up the muscles of extension. Um, and they start with such poor quality, like on the scooter board. And you're like, oh, I'm kind of nervous about you even getting on this thing. Like, you know, and they're not super aware of their body and sometimes they run over their fingers or, you know, all of that stuff.

Um, but sometimes, I'll put that same kid, and or I guess coming back to the scooterboard sctivity. You know, I might, they might start that way and then after three or four goes, you start to see it. Come on. And as long as they're not one of those kids that are, are truly afraid of movement of, of vestibular input, they'll, they're willing to do it usually

[00:39:14] Michelle: like a gravitational insecurity, is that what you mean?

[00:39:16] Cory: Yeah. Because with those kiddos, they won't get on the scooter board. But, So then you kind of do start to see it come on. But are you saying after I, so say I've got a kid who, who I have just done some fast linear input with down a scooter board ramp.

Is there a significance of it, of it being downward angled like that Tracy?

[00:39:35] Tracy: Yeah, there absolutely is. So part of it is that, again, the, the tlr, the Tonic Labrynthine is gonna be communicating about the discrepancy in position between the superior and inferior canals. And when those, the relationship in that changes, then you get a different firing signal.

So when you're in a little bit of head inversion it's gonna do two things for you. First of all, it's gonna orient so that the superior canal is tipped forward, and that's gonna activate extensor control. More than flexor control, and that's what we want in this situation.

The second thing that it does is it activates through the barro-receptors a little bit of a dampening of the, of the overwhelm that's happening autonomically. Yeah.

[00:40:33] Michelle: An inhibition, we're gonna give him a little bit of inhibition so he doesn't freak out. Yeah. Because this will feel intense for him.

[00:40:39] Tracy: That's exactly right. And so this is the kind of, you know, thing where, what you said, Cory, I think in a treatment situation with a child, you have to kind of inch toward this. You don't impose fast linear activation. If the kid is too afraid or their experience thus far has been. This is not successful for me and I don't enjoy this. And please stop it. Then we don't just go forward, right? So we're gonna create the opportunity for that to be successful. Um, but this is what we know the nervous system needs. So you, you don't have to do it through a scooter board ramp. Um, you can, you know, hang up platform swings, lycra swings, you can invert them slightly so that you're getting the same activation.

You, can even use like an inflatable, like a whale or a pillow and kind of do some moving on there. And so you're gonna really explore movement, but your goal as the clinician is to follow - how does that organize the child? Where do they find joy exploration there? How do they pull that system together and how do we start to see that that anti-gravity control is starting to improve?

Yeah, and what we're really wanting is the partner of the vestibular activation to help us with the postural adaptation. And then we wanna work in postural adaptation to work on control against gravity, to work on righting vertically. We wanna start to see the vertical, the, the sagittal plane together through lateral and then rotary movements.

So we're gonna start to pull in some of our knowledge of normal developmental movement patterns. And how those help us. So in the treatment sequence, you're, really weaving together across postural adaptation. From vestibular function up into postural control. And you're just following that, carefully.

This is also, one of the interventions that we've really come to understand that if we can add some sound activation, it's probably gonna be a super powerhouse for us. Because the partner of sound with the vestibular apparatus starts to give a sense of synchrony and, oscillation and that basic vibratory quality of somatic sensory grabbing that, that tone, that rhythm, that beat really fuels the, the deep, um, proprioceptor, the deep somatic sensory receptors, and also vestibular function. And together all of that starts to create a different kind of context that the postural adaptation system starts to get enough richness.

that it's, it grabs onto that information in an integrative way. And so, I know when I'm treating kiddos like this, I really like to weave those pieces together because I find that it just really accelerates progress differently than if I don't put all those pieces together.

[00:44:00] Michelle: Because it adds another, um, group of sensations to add intensity to it, or, or is it the base with which he can start to organize around?

[00:44:11] Tracy: You know, it's really both. Yeah, it's really both, because at the bottom of our chart here, like I said, it's kind of the, you know, the classic triad, but really the auditory system is such a partner to the, to the whole system. Our postural system gives us both - that sustained anti-gravity control so that we can be upright and engaged and start to use our eyes to scan and track and take in the world, close and far, to take in sound close and far, to use our extremities close and far, and that adaptive function of the postural system always includes organizing your body and space. And the sound system helps you tremendously with that. So I think, you know, at some point we'll have an episode maybe where we talk more about auditory as a particular focus. But really what we wanna focus on here is in postural adaptation we wanna analyze the vestibular, somatio-sensory, visual, and auditory functions and pull them and then really on purpose start to use them to build the holding stability patterns.

For the purpose of really fluid movement off of the midline, where the midline is always the referent point. And so the, the midline is the referent point for the core postural system, for your gross motor actions, for your big body actions. It's true for your eyes too, right? And you talked early on Cory, about how this, you know, when you evaluated this young boy that he really was struggling with being able to deal with any ocular pursuit across the midline.

So as soon as he started to get to the midline, His eyes would jump. So that's a real particular ocular finding that is indicative of a vestibular based processing issue that underlies the ocular problem. And so we, we kind of know that from the data that you already collected on him.

But what we wanna do is really look at how the midline organization is going to support that. And as the vestibular function starts to support postural adaptation and you start to have core postural development that's really strengthened and you're gonna see that with that prone extension, becoming really much more at ease. And one of the markers, the real hallmarks there is that you get, an elegant look to that prone extension. And so the integration of flexion/extension produces this kind of controlled anti-gravity control. And really importantly, what you get is no break in the neck complex as the extension occurs. And that starts to tell you that the vestibular somatic sensory relationship that we talked about earlier is starting to be organized. And once that starts to happen, you'll start to see that that ocular pursuit starts to smooth out.

[00:47:40] Cory: Okay. So I just wanted to recap something cause I feel like I got something here that, uh, sometimes it's easy to forget, but, so you were talking about we fire up, we give input to the vestibular functions, so ideally fast, linear input with that slight in inversion. So going down the ramp with their head first, that I guess the function of that is to help provide input to the vestibular system.

Right. But then you were talking about then what we actually wanna target is the postural challenges. So we provide the input, we hopefully get the system firing, so the system does some sort of internal signaling that for, for whatever reason hasn't been super-efficient prior to now.

And so we are increasing and enhancing that, so that we can get better postural function. So better uprightness. And then you were talking about, so once I have that, input provided. Then I'm gonna go into the postural system because that's where we're seeing such huge issues to then. Work in moving my body in space and finding alignment and enjoying the experience of moving my body because I now have activation that I can work off of.

Is that where we’re going from?

[00:48:56] Tracy: That's exactly, yeah, that's right. And then you're gonna have all kinds of really fun opportunities to explore moving through space with all different qualities. Finding balance and equilibrium in all different levels of challenge. Dynamic and static challenges.

And, and that system is gonna really synchronize and organize. So at the end of the day, postural adaptation is super deeply related to functions like balance and bilateral coordination. Yeah. and we didn't get into

Cory: and midline.

Tracy: And midline, yeah, that's right. So those, those skills that, that are at the higher end of this.

But um, yeah, so it, it's all the postural adaptation system as you work from the sensory base through the sensory motor functions that support it. Um, that's what gives the background automatic. Ability, capacity to, to be a hand writer that he doesn't have.

[00:50:06] Cory: Wow. What a great way to end.

[00:50:06] Michelle: I love that and I love that it's auto automatic.

Like he shouldn't have to think about it and he shouldn't have to plan for it. That so that when he tilts his head back or whatever, that his body. Integrates that new input and,

[00:50:23] Cory: Adapts, postural

[00:50:24] Michelle: Adapts Yeah. Whatever to whatever demands you're doing. Yeah. So follow this visual thing. Yeah. You know, hop in this posture and hold, move in and out of this.

Yeah. Anyway, Automatic,

[00:50:36] Cory: So fascinating. And when it's not automatic, you get breakdowns in function.

[00:50:40] Tracy: Yeah, when it's not automatic, you have to lean on your arm and then you have to stop after two minutes. And it doesn't, it doesn't get better with practice. You only get better by addressing the underpinning. And that's the beauty of the work that we do. So what a great case, Cory. I love it.

[00:50:56] Cory: Yay. Thanks Tracy. That was, Yeah, that was great. We will put the, link up in the show notes for that postural graphic. Tracy who, put it together?

[00:51:09] Tracy: So that graphic has, been adapted over the years. Yeah. But it really came from Anne Grady, who was one of my bosses. And, she did a lot of teaching in the world of, neurodevelopmental treatment in NDT, but she was also, taught a lot of courses just on development and how do we support kids in development and their occupational performance.

So that, chart really was adapted from Anne Grady, from years ago at Children's Hospital in Denver. And it's a joy to be able to share it in this form.

[00:51:46] Michelle: Yeah, it was really useful cuz to unpack it using that image. So thanks for bringing that Tracy, that’s accessible for everybody else too have a look at, have a look at while they listen.

Other Books/Resources Mentioned:

• A. Jean Ayres, 1972. Sensory Integration and Learning Disorders. Chapter 6: Postural Control. Western Psychological Services.

• A. Bundy., & Shelly J Lane. 2020. Sensory Integration Theory and Practice, 3rd Ed.