|
 Emma
is an 18 month old little girl referred to our facility
in early 2006 for a speech language evaluation. Emma’s
diagnoses include Aicardi Syndrome, Agensis of the
Corpus Callosum (complete), seizure disorder, cerebral
palsy, failure to thrive and global developmental
delays. Mother reported that Emma’s specialists had
predicted that "best-case scenario, Emma might one day
sit unsupported" and that her family should not develop
expectations beyond that. The family had been advised to
equip their home for wheelchair access and to plan on
life-long, one-on-one care for Emma.
Emma was
referred to our Speech Therapy Clinic due to
communication
delays and
severe sensory integration deficits. At the time of
initial evaluation Emma was 7 months old and her mother
reported that Emma displayed only one vocal sound, cried
only when in pain, exhibited a severe startle reflex and
appeared to have limited visual skills. Results of a
language assessment indicated an age equivalency of 4
months for receptive language and a 2-3 month age
equivalency for expressive language. A plan of treatment
was begun utilizing traditional pre-linguistic therapy
modalities including oral motor stimulation,
introduction of cause/effect toys, prompting of
imitation and numerous sensory integration techniques.
Emma was reassessed at 18 months.
Results of that assessment indicated a minimal gain with
a standard score of 67, %=1 in auditory comprehension
and a standard score of 60, %=1 in expressive
comprehension for an overall age equivalency of less
than 10 months. Emma’s mother described her as "a floppy
rag doll" who slept 18-20 hours a day and exhibited no
desire for interaction or contact with any other person.
She reported that she was unable to kiss Emma due to
hypersensitivity on her face, hands and feet. At 18
months Emma would refuse any food other than her baby
formula. Mother described Emma’s sensory deficits in
feeding as "the three Ts" (temperature, taste and
texture) and reported that any change to the "Ts" would
result in a total rejection by Emma and typically she
would get so upset as to vomit.
At 18 months Emma’s functional deficits
included total lack of core and trunk tone, inability to
sit unsupported, total lack of prone positioning, no
protective balance reflex, no step reflex, no crossing
of midline, no reach/grasp behaviors, no pincher grasp,
limited visual tracking, no eye contact, frequent
rocking and head banging, limited and infrequent sound
productions with low volume (whispers). Emma displayed
very limited localizations to her name and visually
seemed only to fixate on large geometric color blocks.
Based on our clinical experience with
Interactive Metronome (IM), past successes in modifying
the program to include hand-over-hand assistance,
knowledge of the neuro rehabilitative basis of the
program and most profoundly, a sincere motivation to
achieve the best possible outcome for this sweet little
girl, lead us to propose IM as a therapeutic modality to
Emma’s parents. Though (they later admitted) doubtful of
the potential for improvements, they felt they had
"nothing to lose" and agreed to "try it and see."
Due to Emma’s severe hypersensitivity to
touch, startle reflex and aversion to sound making
toys/equipment, we began IM using stereo speakers rather
than headphones. Initial sessions were no more than
10-15 minutes working primarily on hand movements.
Because of insurance restrictions, Emma was seen only
twice weekly. Though more than one therapist worked with
Emma, we would typically hold her in our lap facing away
from us and would hold her hands in ours. This
positioning allowed the therapist not only to
comfortably support Emma upright in a sitting position
but also to move her hands while holding the trigger
securely in her palm. Emma was completely flaccid and
offered no resistance. We incorporated individual right
and left hand movements into our sessions with Emma
still seated in the therapist’s lap and maintained
approximately the same task average.
Emma’s mother reported that after the
first IM session Emma laughed out loud. She related that
Emma was lying on the living room floor while her
parents were in the next room. They heard a noise and
rushed back in to the room to find Emma looking at the
TV and laughing. They had never heard Emma make a noise
above a whisper much less look at the TV. Though they
were hesitant to attribute the laughing to IM they
continued to see new behaviors after each IM session.
Emma’s sensory issues began to improve dramatically.
We were able to progress Emma to wearing
the headphones draped loosely around her neck for very
short periods, initially for 1-2 minutes and eventually
to wearing them on her ears for the entire session. We
found that
she more easily accepted the
larger, padded headphones which surrounded her ears
rather than the type that rest on them.
To complete
exercises involving her toes, heels, and cross-over
(hand/toe);
we
positioned Emma in her mother’s lap facing the
therapist. We sat on the floor and completed the
exercises with two hand triggers wrapped around
Emma’s
shoes.
As our
sessions evolved, Emma became more responsive, extending
her
hand to have
the trigger strapped on, making eye contact as the
therapist talked or sang to her during the exercises and
would try to assist in making the movements. She would
turn her cheek for a kiss rather than shying away from
the touch. Emma would finally take a sippy cup and in
fact would take any sippy cup, not just one particular
style or brand. She began to eat some soft table food
and would drink water and juice. Emma was sitting
unsupported and her physical and occupational therapists
were reporting amazing improvements including a
rudimentary crawl. She developed a moderate
righting/balance reflex, had begun some bearing of
weight on upper and lower extremities, was crossing
midline and using a pincher grasp. From a
cognitive/communication stand point Emma was improving
by leaps and bounds. After just 3 IM sessions her mother
reported a marked increase in Emma’s babbling and vocal
volume. She consistently localized to her name and
familiar people and displayed a direct imitation of
speech sounds such as mouthing "Momma" and "bye-bye."
Emma now makes and maintains eye contact, smiles and
shows emotion. Her startle reflex is
greatly reduced and she is totally non-defensive when
her feet or hands are touched.
The most
touching of the reports from the family came from Emma’s
father who is a Navy sailor. He went on extended sea
duty just after we began using IM with Emma and returned
3 months later. After spending two days
at home with
Emma, he tearfully said "for the first time ever, she
knows who I am. She recognizes me when she sees me."
We discontinued IM after 5 months with
plans to continue at a later date. Emma is still seen in
our clinic and is walking with a gait trainer, learning
sign language and is enrolled in special education
classes with our school district. Everyone in Emma’s
life can testify to the global improvements she made as
a result of IM. Intense language therapy is now the goal
in order to teach hierarchical skills to her improved
neurological pathways.
We would encourage any therapist working
with a neurologically involved client to consider IM.
Using IM as a therapy tool for Emma has greatly altered
our way of evaluating the candidacy of a client. We no
longer feel that the client must be of a specific age
and/or able to use the program on a progressive,
independent basis. We have seen that the brain networks
as a result of motor movements and timing regardless of
who supplies the responses. We make no promises to
parents who are pursuing IM as a part of their child’s
therapy because every little brain is different and
every child displays their own unique characteristics.
But for the most part, parents are willing to try most
anything to help their child and when told the story of
Emma they are excited about the possibilities.
Have fun fellow therapists! We CAN
change the lives of children and their families.
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