AYRES SENSORY INTEGRATION

PRINCIPLES: AN APPLICATION TO TBI

Created By: Erin Bachler, OTS

Guiding Principles
• Sensory Integration – The organization of sensations that allows us to adequately
respond to environmental stimuli.
• Sensory Integrative Dysfunction – An irregularity or disorder in brain function
that makes it difficult to integrate sensory input.
• Sensory Processing – generic term used to describe the way in which sensation is
detected, transduced, and transmitted through the nervous system.
• Sensory Modulation - the process of increasing or reducing a neural activity to
keep that activity in harmony with all the other functions of the nervous system.
• Sensory Discrimination – ability to interpret and make meaning of different
sensations
• Adaptive Response - An appropriate action in which the individual responds
successfully to some environmental demand.
• Just the Right Challenge – Challenges should be presented to the individual that
are “hard” but not so hard that the person will fail. (Ayres, 1972)
 Theoretical Base and Main Hypotheses
• Theory Base: Sensory integration is the brain’s ability to organize sensory information received from the body
and environment, and to produce an adaptive response.
• Assumptions:
◦ Sensory systems do not develop independently of one another
◦ Perceptual Awareness supports and facilitates occupational engagement
◦ Motor Learning is dependent on incoming sensation
◦ Body awareness creates a postural model to understand visual-motor development
◦ Postural control is essential for skilled motor performance.
◦ The ability to focus and maintain attention and to keep a steady level of activity, and in the way in which the
nervous system responds to tactile sensation, are related.
◦ Sensory systems develop in an integrated and dependent manner
◦ Visual and auditory processing depend on foundational body-centered senses. (Ayres, 1972)
SENSATION REVIEW
Exteroceptors
Sensations That Tell Us What is Coming from Outside the
Body
•Sight (Visual Sense)
•Sound (Auditory Sense)
•Taste (Gustatory Sense)
•Smell (Olfactory Sense)
•Touch (Tactile Sense)
(Ayres, 2005)
Proprioceptors
Sensations That Tell Us Where the Body is In Space and How
it is Moving
• Position and Movement (Proprioceptive Sense) – Input received
from our muscles and joints that tell us where we are at in space.
• Vestibular (Gravity, head movement, balance) - located in the inner
ear and it coordinates your body’s movement and balance as well as
movement of your eyes separate of your head (e.g. visual tracking,
saccades, convergence/divergence)
(Ayres, 2005)
Interoceptors
Sensations that Tell Us About the
Inside of the Body
• Interoception - S ensation relating to
the physiological condition of the
body. These receptors are located
internally and provide a sense of
what our internal organs are feeling.
For example, a racing heart, hunger,
thirst, etc.

(Ayres, 2005)
Sensory Modulation
• Lower Brain Function
• The organization of sensory information for ongoing use.
• Poor modulation skills result in individuals entering a “fight, flight, or freeze”
mode. This can be due to high levels of stress, anxiety, perfectionism, etc.
• Often under or over responsive to sensory input

Under Responsiveness Over Responsiveness

Input is not perceived by the CNS when
present in a normal amount
Individual requires more input to register
that something is happening
Disarray in response to sensory input as a
result of an overactive CNS
Difficulty “tuning out” non-important
sensory input (easily distracted)
(McKenzie, 2017)
Sensory Discrimination (Ayres, 2005)
• Higher brain function
• Ability to interpret information and make meaning of incoming sensations
• Examples:
oAuditory – Did she say pattern, tattered, or scattered?
oTactile – Is that a paperclip or a safety pin in my pocket
o Visual – where is the coin that looks like this?
oProprioceptive – How high do I have to reach to grab that item I need off the
shelf?
oVestibular – Which way am I turning?
 FACTORS THAT
IMPACT SENSORY
DYSFUNCTION
The Triune, 3-Part Brain (Van der Kolk, 2014).
The Prefrontal Cortex
◦ Planning and anticipation
◦ Association between time and context
◦ Inhibition of Inappropriate actions,
◦ Empathetic Understanding

The Limbic Brain

◦ Map of relationship between organism and surrounding.
◦ Emotional Relevance
◦ Categorization, Perception
◦ The Mammalian Brain -

The Brainstem
◦ Arousal
◦ Sleep/Wake
◦ Hunger/Satiation
◦ Breathing
◦ Chemical Balance
◦ Reptilian Brain
Typical Sensory Integration Process (Ayres,
1972)
Sensory
Input

Adaptive
Response Brain

Information
is combined Meaning
with is Given
previously to the
shared info Input
Sensory Processing Dysfunction (Ayres, 1972)
Sensory
Input

Maladaptive
Response Brain

Information
is combined Meaning
with is Given
previously to the
shared info Input
The Role of Arousal
• Arousal: The state of the nervous system, describing how alert one feels.
oOverstimulation – too aroused
§ Sensory shutdown: Lethargic, Disengaged
§ Hyper: Hypervigilant, Impulsive, Unsafe
◦ Underestimulation – under aroused
§ Lethargic – as a result of not having enough sensory input
§ Hyper/Sensory Seeking - seeking sensory input to try and keep alert.

• Self-Regulation: The ability to attain, maintain, and change arousal appropriately for a task or
situation
(Williams & Shellenberger, 1994)
INTERESTING PAST
LITERATURE
Why is it Important?
◦ Alwis et al., 2013 noted that most individuals that sustain a TBI show changes in
how they process sensory information, and because sensory input and its
processing are critical to understand the world and guide complex behaviors,
sensory processing may easily affect these behaviors.
◦ Galvin et al. reported changes regarding enhanced sensitivity in visual, auditory,
and touch processing in pediatric TBI patients for a year after injury after
administering an assessment scale to caregivers (2009)
◦ Ding et al. 2011 found that immediately following brain injury there is a global
suppression of sensory cortical responses in the somatosensory cortex, as well as
20 minutes after injury. This is followed by a period of increased activation above
baseline activity at 2 hours after injury.
Effectiveness of Sensory Stimulation to Improve Arousal and
Alertness of Those in a Coma or Vegetative State After TBI

• Systematic Review: Padilla & Domina (2016)

o Examined 9 studies
o Studies addressed unimodal stimulation, multimodal stimulation, and nerve stimulation.
All used the GCS as a primary of secondary outcome measure

o Results:
§ Multimodal sensory stimulation improves arousal and enhances clinical outcomes for people in
a coma or persistent vegetative state after TBI.
§ Auditory Stimulation – Moderate evidence was provided (unimodal stimulation)
§ Median Nerve Stimulation – Insufficient evidence was provided.
Balance and Postural Differences
◦ Lin et al. (2015) conducted a study on 107 patients with mild TBI and 107 healthy controls in Tawaiin
◦ Measures:
◦ Dizziness Handicap Inventory (DHI), The Balance of postural-stability test and the modified clinical test of
sensory integration and balance (mCTSIB) were both measured using the Biodex Stability System
◦ Balance of Postural Stability and mCTSIB were conducted within the first week following injury

Results:
Comparison of Two Sensory Stimulation Models in Adults with Severe
TBI (Chauaykarn & Jitpanya, 2017).
• Subjects: 45 TBI patients were randomly assigned to:
◦ Group A: Treated by multimodal stimulation model. The program composed of
auditory, visual, tactile, and kinesthetic stimulation. Stimulation sessions lasted 30
minutes and were carried out 2x/day for 2 weeks.
◦ Group B: Treated by sensory stimulation including auditory, visual, olfactory,
gustatory, and tactile stimulation. Stimulation sessions lasted 15-30 minutes at 5x/day
for two weeks.
◦ Group C: Conventional Care (turning position by nurses, passive exercise movements,
and oral care)
◦ Outcome Measure: Coma Recovery Scale Revised (CRSR) measured at baseline, and 1st
day to 14th day of intervention
◦ Results: Group A had higher CRS-R scores after day 7 through to day 14 over groups B
and C, suggesting evidence for the effectiveness of multimodal sensory stimulation.
 Sensory Intervention Effects on EEG
Patterns (Gomez et al., 2016)
• Subjects:
◦ Experimental Group: 18 subjects with TBI and 18 with Cerebral Palsy
◦ Control Group – 18 healthy volunteers

• Results: Results yielded that for the TBI group, Snoezelen therapy affected the
CNS, inducing a slowing of oscillatory activity and a decrease in EEG complexity
and irregularity.
 TREATMENT
CONSIDERATIONS
Vestibular and Proprioception Treatment
Considerations
• Proprioception – After engaging an individual in proprioceptive
activity, it is possible to see benefits to the CNS for up to 2 hours.
◦ Examples: Jumping, exercising, heavy work, etc.

• Vestibular – Input to this system can impact the CNS up to 8

hours
◦ Ex. Swinging, Astronaut Training, Using the Wii Balance
Board, etc.
References
◦ Alwis, D.S., Johnstone, V., Yan, E., & Rajan, R. (2013). Proceedings of the Australian Physiological Society Symposium: Brain Dysfunction and Translational Neurophysiology.
Clinical and Experimental Pharmacology and Physiology, 40, 473-483
◦ Ayres, A.J. 2005. Sensory Integration and the Child: 25th Anniversary Edition. Los Angeles, CA: Western Psychological Services Publishers.
◦ Ayres, A. J. (1972). Sensory integration and learning disorders. Los Angeles: Western Psychological Services.
◦ Chuaykarn, U. & Jitpanya, C. (2017). Effects of Two Sensory Stimulation Models on Recovery in Adults with Severe Traumatic Brain Injury. International Journal of Medical Research
& Health Sciences, 6, 69-74.
◦ Ding MC, Wang Q, Lo EH, Stanley GB. Cortical excitation and inhibition following focal traumatic brain injury. J. Neurosci. 2011; 31: 14085–94.
◦ Galvin J, Froude EH, Imms C. Sensory processing abilities of children who have sustained traumatic brain injuries. Am. J. Occup. Ther. 2009; 63: 701–9.
◦ Gomez, C., Poza, J., Gutierrez, M.T., Prada, E., Mendoza, N. & Hornero, R. (2016). Characterization of EEG patterns in brain-injured subjects and controls after a Snoezelen®
intervention. Computer Methods and Programs in Biomedicine, 136, 1-9.
◦ Li-Fong Lin, Tsan-Hon Liou, Chaur-Jong Hu, Hon-Ping Ma, Ju-Chi Ou, Yung-Hsiao Chiang, Wen-Ta Chiu, Shin-Han Tsai & Woei-Chyn Chu (2015) Balance function and
sensory integration after mild traumatic brain injury, Brain Injury, 29:1, 41-46, DOI: 10.3109/02699052.2014.955881
◦ McKenzie, A. (2017, November). Sensory Processing Skills and Self-Regulation. [Presentation Slides]. Retrieved from https://www.foresthills.edu/content/documents/November-1-
2017-Understanding-Sensory-Processing-Powerpoint.pdf
◦ Padilla, R., & Domina, A. (2016). Effectiveness of sensory stimulation to improve arousal and alertness of people in a coma or persistent vegetative state after traumatic brain
injury: A systematic review. American Journal of Occupational Therapy, 70, 7003180030. http://dx.doi.org/10.5014/ajot.2016.021022
◦ STAR Center Foundation (2017). Understanding Sensory Processing Disorder. Retrieved from https://www.spdstar.org
◦ Van der Kolk, B. A. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. New York: Viking.
◦ Wilbarger, P. & Wilbarger, J. (1991) Sensory Defensiveness in Children 2-12: An Intervention Guide. Avanti Educational Programs, Denver.
◦ Williams, M.S., and Shellenberger, S. (1994). How does your engine run? Albuquerque NM USA: Therapy Works.