By Interactive Metronome - September 1, 2017

Helping Hard Hitters!

Do you have patients that are hard hitters? We are here to help! We are here to provide you with a few helpful hints and share how other clinicians like yourself solve the ‘hard hitting’ issue when ‘clap more softly’ isn’t working.

Modifications are often necessary in order for your client to be successful and attain repetition of a task to the beat. IM is often the first opportunity that your client will be able to experience accurate feedback to their innate timing tendency.

Q: What are some techniques to use with kids who have Sensory Processing Disorder, fast tempers or other circumstances where they can’t seem to control how hard they hit the triggers?  Asking them to hit more softly just doesn’t seem to work.  I’ve tried cushioning the triggers – which typically is just a distraction and they fiddle with it.

A: This is a great question and a problem that pops up a lot with many clients presenting with dyspraxia/motor coordination problems. They can be extremely hard on the triggers and also feel pain from the impact onto their other hand! It is important to remember that they do not do this on purpose; it is an intrinsic deficit that will not respond to verbal cues such as, ‘clap more softly’. If a solution that works for the client is not found, then it can become a real hindrance to becoming engaged with their IM training.

Here are a few ideas we found that other IM Providers have used to overcome ‘hard hitting’ and stay committed to IM training.

Trigger Modification Solutions and Considerations:

1) Create a motivational connection:

As with all modifications, try to find a motivational aspect to connect to. Create a list of activities that the client enjoys, or aspires to engage in. These may include sports, hobbies, celebrities or characters that they admire.  For older clients, discuss other circumstances that clumsiness or difficulties with graded force pressure may impact. This may include instances where the individual may repetitively do something in public that embarrasses him, such as tripping frequently on curbs etc.; knocking things over (i.e. A drink in a restaurant); pressing so hard with a pencil that the lead breaks; having difficulty accurately putting on makeup; bumping into things and/or people.

The key is to find something that the client can connect to. This will help him to work through not only the physical challenge but also the emotional impact and frustration that this has on his functional performance.

2) Combine trigger with other items that may provide a buffer:

This can be as simple as thinking, “What can I put into the client’s hand that will buffer the impact of the forced pressure?”. With this client group, we can safely say it will not be a hammer! Here are some buffer items that have helped in the past:

* Squishy bug toys

* Foam/soft balls

* Favorite characters (i.e. Pikachu, Barbie or angry birds)

* Marinating brushes with ‘mop’ material at each end

* Soft-ended drumsticks

* Pencils with an eraser on the end to be used as a shock absorber

* Piece of pool noodle – try different lengths to align with the trigger

Holding the buffer item in one or both hands and bringing it to the trigger influences the momentum force of the movement. The trigger can be placed on the client’s hand while the buffer is held in the other to prevent the force from an open palm hitting the trigger. Alternatively, the buffer may be held in each hand and the trigger placed in front of the client. For example, strap the trigger onto their knee while they are seated in a chair or placed on the floor in front of them while they are seated in round sitting or in prone position.

3) Add tools to the trigger that will protect it and facilitate successful IM training:

There are many ways to influence the impact of force onto a trigger, this can be done purely from a physical concept or paired with a client’s motivational interest. Here are some examples to get your creative juices flowing:

* The ‘Hamburger Patty’

Purchase a large car-washing sponge, lay it flat on a surface and make a horizontal slice halfway through as if you were cutting a hamburger bun. Then, using scissors cut and scoop out a space for the button trigger inside the sponge. This needs to be deep enough to hold the trigger in place and allow enough space to ensure that the trigger does not depress when the trigger is placed inside the sponge.  Place the trigger inside the sponge and position the sponge onto the floor. Have the client kneel in front of the sponge and press down onto the sponge with one or both hands to the beat. The cushioning effect of the sponge will protect the trigger and absorb the impact of the force pressure. Note: Tempo for this activity may need to be decreased to allow time for the client to adjust to the movement.

* The ‘Catcher’s Glove’

Purchase a baseball mitt. Apply a strip of self-adhesive soft Velcro inside the palm of the mitt. Attach the button trigger to the Velcro strip so that it is positioned inside the palm of the mitt. Have the client wear the mitt on one hand and clap into it with the other hand. Due to the shape of the mitt, the clapping motion will need to be more guarded and require more control, which in turn will slow down the impact of force pressure. This principle can be adapted to any toy/item that you can affix to one hand. Avoid using a ‘Hulk’ glove … just far too much excitement in my experience! 😉

* Frosty the Snowman Gloves

Purchase a pair of stretchy winter gloves or mittens. Place the button trigger onto one hand. Place the stretchy glove/mitten on the same hand over the top of the trigger. Place the other glove/mitten on the client’s other hand. This will provide the much needed cushioning and protection for both hands and trigger when clapping.

* ‘Inside the box’

Make or find a box that the client’s hand can fit inside comfortably. Make two incisions at the base of the box to thread the button trigger strap through. Have the client place his hand flat on the back of the box and wrap the button trigger strap around their hand to secure the box to the palm of the hand (you may need a larger strap or connect two straps together). Place the button trigger onto the strap threaded through the inside of the box. On the beat, have the client reach into the box with the other hand to tap the trigger. Depending on the span and depth of the box this may be with a flat hand or with outstretched index fingers. Characters that work well with this activity, for creativity, are the Box Trolls.

4) Adjust the physical layout of the training environment:

How you set up the physical layout of an IM exercise will involve where you place the trigger in relation to your client and also how you position your client in relation to the trigger. Here are some examples you can try:

* Place the trigger underneath the corner of a treatment mat or under a pillow and have your client reach down to depress it. It is important for the mat not to be too heavy so that it is not depressed between hits.

* Decrease the lever-arm of the movement by attaching the button trigger around the client’s elbow and have them clap from alternate hand to opposite elbow. This reduces the momentum of the swinging motion and adds novelty, which in turn can improve control.

* For many clients impact of force pressure is greatest in extension positions (i.e. standing). Changing this position to include flexion components can reduce force pressure. For example, Hold a hula-hoop in front of your client at waist height and have them reach inside the hoop with slight hip flexion while clapping.

* Incorporate gravity. Have your client lie on the floor and raise both hands towards the ceiling to clap in a circular motion against the resistance of gravity.

* Break up the pattern of the movement. Place the button trigger on one hand and have your client tap their opposite shoulder; wrist; elbow; hand; hip; knee; ankle. Movements may be sequenced one at a time or in a series. For balance: have your client stand with their back against a wall, stand with their back to the corner of a room or lie down with their back on the floor.

* Include a movement sequence. Have your client clap with hands in front; with hands above their heads; with hands behind their backs in a sequence.

* Try modeling with your client. Use hand over hand assist, high fives or turn taking during clapping. For example: I’ll clap for 5 beats then you clap for 5 beats while each person using a trigger.

* Position client in a forward flexion position to control momentum force of his arm swing. For example: Lying on their back in a hammock, compressed inside a mushy beanbag or inside a large cardboard box!

Modifications are often necessary in order for your client to be successful and attain repetition of a task, at the same time keeping to the beat. You have to remember that IM is often the first time in their lives that your client will be able to experience accurate feedback to their innate timing tendency. Assessing feedback to their timing response is key, so customizing tasks with short repetitions, an increased frequency at the beginning of IM training is essential. Difficulty settings should start at 300, with the burst at setting 2. Tempo will vary based on the modification, a slower tempo will slow down momentum, but too slow a tempo will increase the difficulty of the task and increase frustration, so try out different tempos with your client to find out what feels the most comfortable and achievable. Tempo can be increased a little at a time, try 1-2 beats as your client progresses.

Ultimately, each client presents with his own unique set of challenges. IM allows us to respond individually to these challenges and help our clients to work through and overcome these difficulties. Novelty, creativity, modifications and an abundance of patience will improve your client’s success with IM training and your expertise as an IM Provider!

Thank you to Mary Jones, OTR/L, LMT, CIMT for these helpful suggestions!