By Amy Vega - July 16, 2014

Resistant client? Motor deficits may be the root of the problem

Question:

I am working with a student who is very resistant. He asked me to keep the times for each exercise to 1.5 minutes rather than lengthening to 2.5 minutes, which I did anyway. At 2.5 minutes, his performance was significantly worse. Since he is a high school student, I wanted to lengthen the attention interval. I don’t know if the problem is that we exceeded his attention span or if he is resentful and does not want to cooperate.

What is more important for improving attention, lengthening the attention interval or keeping it short and improving the timing? That is, I could go back to 1.5 minutes for each of 14 exercises, and I might get an improvement in timing, but only 14 minutes of training for the student. 

In addition, I can’t get him to do the movements correctly. He will leave both heels on the pad and just lift then stomp one at a time. He won’t do round motion with both hands, he kind of taps them together. Is it important to focus on the quality of the movement? He is used to doing this type of thing to distract from the work he needs to do, and I thought it was more important to keep him working than to perfect the movement. His scores were as follows:

Answer:

The key here is that he is unable to correctly perform the movements and that his movements are not circular. It appears he may have dyspraxia – impaired motor planning and sequencing; this makes IM training very frustrating and ties up his cognitive resources, especially processing and working memory. It is important to observe the quality of motor movements during the LFA and early in training when guide sounds are first turned on. If you see choppy, hesitant, linear, or poorly sequenced movements, then you will want to begin IM training with just the reference tone, a slower tempo, and hands-on assistance/modeling of the correct movement to remediate dyspraxia in Phase 1 of training before proceeding to Phase 2 (guide sounds). A person that has dyspraxia cannot respond appropriately to the guide sounds very well because when they volitionally adjust motor movements to get more in sync with the beat the body does not respond correctly – this is very frustrating for the person who is training. He may require more IM training sessions than a person who does not display this problem with coordination.

In this case, it is critical to back up and work on motor planning and sequencing first, then processing and other cognitive abilities will begin to improve. 

Here is what I recommend:

1.       Turn off guide sounds so you have REF TONE only.

2.       Do NOT use visuals – he should do auditory only.

3.       Reduce the tempo slightly and find the just-right, slightly slower tempo that allows him to make the circular movements consistently (this may be anywhere from 48 – 52 bpm). Experiment to find the right one.

4.       Provide hands-on assistance for timely, rhythmical (circular) clapping of both hands and tapping of right hand/left hand (exercises 1 – 3). Set exercises for progressively longer duration so that the exercise does not end just when he is “getting it” and improving praxis. With you doing hand-over-hand, his motivation does not matter – but your own timing DOES matter. Ideally your own timing is in the 20ms or better range to really be helpful. Try to make as many hands-on hits within the 0 – 15 ms range as you can. DO NOT BE CONCERNED ABOUT HIS OWN SCORE. His scores do not matter right now – only his ability to clap/tap rhythmically which he will learn with your assistance.

5.       Over time, begin to wean from total hands-on assist to allow him to clap/tap rhythmically on his own – jump back in and give more hands-on assistance as needed. Still, don’t worry about his score.

6.       Once he can make rhythmical movements consistently to the beat, watch the screen and see if he begins to make hits in a tighter range (rather than bouncing around early – late – early, and even begins to make a lot of very early hits showing increased fluidity of movement). When this happens, adjust the tempo slightly faster toward 54 bpm WITHOUT TELLING HIM that you are doing so (that way he will not TRY harder – when he TRIES and thinks about his movements that is when the motor sequencing goes haywire, (it is a problem of VOLUNTARY motor movement) but if he claps rhythmically to the beat WITHOUT THINKING ABOUT IT then he will improve his motor planning and sequencing skills. So, do not provide verbal or visual cues for IM training. If you decreased it to 50 bpm, you would increase to 52 bpm for a while until he is doing well and maintains rhythm, then increase to 54 bpm.

7.       Do not address the foot exercises until hands are mastered and he is rhythmical. When working on the lower extremities, it may feel like you are starting from square ONE!! He is exhibiting significant dyspraxia in the lower extremities. Also, it is important to note that he will likely require substantially more IM training sessions than someone who does not display dyspraxia, as he has to take a more graduated approach to remediate the problem before he can benefit cognitively. Researchers have discovered that there are shared neural pathways for auditory/cognitive processing and motor planning & sequencing. When motor planning/sequencing is affected, valuable cognitive resources are tied up in motor tasks like handwriting and coordinating movement so that attention, processing, working memory and executive functions are not functioning optimally. Below is information on how to address the lower extremities when he is ready.

How do you recognize motor planning and sequencing problems during IM?

• – hesitant movements
• – small movements
• – linear movements (instead of circular)
• – extraneous movements that occur periodically
• – can’t make smaller adjustments in timing. When hears guide sound, overcorrects and hits very/early – very/late – very/early
• – during LFA you will notice trouble with sequencing Both Toes, Both Heels, R Heel/L Heel, Bilateral tasks (in these cases, it will not be as readily seen in the hands, but will be present in the form of the person not being able to lower ms scores – he will tend to over or under correct instead of making smaller adjustments. He will have trouble achieving bursts. He may step onto foot trigger then not step off and sequence the feet appropriately. He may get frustrated and display poor motivation toward IM training).

If the person can achieve good ms timing scores (e.g. in 20 – 30 ms range), but movements are small and linear rather than circular and rhythmical, he likely is still exhibiting motor planning & sequencing problems (or dyspraxia). It is important to go back and address this dyspraxia before moving to the feet. To improve motor planning & sequencing (and fine motor control) of the hands, try a slower tempo and work on making circular movement with the guide sounds OFF. Provide hand-over-hand assistance during longer sets of IM (e.g. 5 – 10 min tasks), weaning from your physical cues as he is able to maintain rhythm. As the person demonstrates more fluid, rhythmical movement, turn on the guide sounds. As he continues to make smoother, more rhythmical movements that are better timed (e.g. can keep ms scores for each hit in a tighter range and make smaller and more accurate adjustments to guide sounds – especially in response to the Right On guide sound), then begin to increase the tempo back to 54 bpm. Make sure to keep tasks set for a high level of repetitions to iron out the motor planning problems. Once hands are mastered, move to the lower extremities. Here are modifications for foot tasks for a person with dyspraxia (motor planning & sequencing problem).

Modifications for IM foot exercises

Many people (both adults and kids) with rhythm and timing deficits have particular difficulty with motor planning and sequencing in the lower extremities. Try these methods (Toe tasks are described below, but the same strategy applies for the Heel tasks):

• – BEGIN WITH R Toe AND L Toe. HOLD OFF ON BOTH Toes UNTIL MOTOR PLANNING IS BETTER WITH EACH Toe INDIVIDUALLY. IF Toes ARE REALLY AWEFUL, YOU MIGHT CONSIDER DOING BILATERAL TASKS FIRST TO GET BILATERAL HEMISPHERIC COMMUNICATION GOING.
• – Turn guide sounds off initially (even though may be using guide sound with hands).

• – Reduce the tempo to between 45 – 52 bpm if necessary. You are looking for movement to become easier, less hesitant, better sequenced, so strike a balance between the speed of the metronome and quality of movement. Some individuals only need the tempo reduced to 52 bpm to accomplish better motor planning & sequencing.  
• – Have the person imitate you as you step on the foot trigger on one beat, then off the trigger on the next beat, then on the trigger on the next beat, then off the trigger on the next beat…rather than tapping. When motor planning problems are present (and even impulsivity), it is much easier to regulate timing with a stepping pattern instead of tapping.
• – If balance is an issue, do tasks while seated to allow for greater focus on timing or allow person to hold onto something for stability (this will be far less distracting).
• – Gradually work toward stepping onto the foot trigger on each beat (instead of every other beat), still with the person imitating you.
• – Gradually work toward tapping the toe on the trigger on each beat, incorporating the hip in the movement so that the body is rocking onto the trigger (instead of isolating the ankle and foot in tapping). The person may need you to have your hands on his hips, facilitating this rocking motion since motor planning problems can make it difficult to incorporate so many joints in the task (hips, knee).
• – Do lots of repetition (e.g. set tasks for 5 – 10 minutes at a time) with breaks in between tasks as needed to remediate the motor planning problem. As the person works at this slower tempo at a high number of repetitions, you will literally see and he will feel the movement become easier and more fluid. That is when you will gradually increase the tempo back to 54 bpm.  

As you can see, some hits will not register on the IM when doing on/off rhythm…no sweat.

This same strategy applies to working on Heel tasks.

Amy Vega, MS, CCC-SLP

Interactive Metronome, Inc

Clinical Education Director

Clinical Advisory Board Director

Clinical Education Administrator