The Bilateral Integration and Sequencing Profile (BIS (T))

1. The Bilateral Integration and Sequencing Profile (BIS (T)) The vestibular-proprioceptive system and coordinating left and right side of the body Do not use or distribute without written permission.

2. Vestibular and BI Deficits • Involves inefficient vestibular processing associated with poor postural, ocular, and bilateral function • Delays in developing postural mechanisms, balance, ocular motor control, bilateral integration, and sequencing. • Smith Roley et al. (2015) showed relationship between vestibular perception and balance skills in children with ASD Do not use or distribute without written permission.

3. Bilateral Integration and Sequencing • As praxis develops it proceeds into higher forms of organization • Consider the “Bilateral Integration and Sequencing” profile, which requires both sides of the body to do all of the above processes of praxis in more precise timing and sequencing. • Higher order thinking has much to do with co-existing processes of thinking/planning with inter-hemispheric organization between left and right brain. • This sets up the ultimate goal of having great executive functioning skills, which would include timely responses from all senses at the same precise timing leading to having adequate ability of being a functioning school student that embraces learning. • Generally more subtle to observe • Slouching or difficulty staying upright / seated at desk for long periods of time • Poorly coordinated use of the two body sides combined with deficits in sequences of movement • Right-left confusion • Poor lateralization of hand function • Avoidance of midline crossing • Poor ability to skip, jumping jacks, stride jumps • Difficulty catching and throwing a ball Do not use or distribute without written permission.

4. Inter-Hemispheric Organization • Transfer pre-motor commands, transferring lateralized information such as verbal or visuo-spatial activity • Once movement begins – feedback sensory signals are activated to control bi-manual movements that are not synchronized, inhibit opposite hemisphere from interfering • Separate programming in each hemisphere of motor-act planning and asymmetrical transfer of information between the hemispheres • Geffen et al., 1994 Do not use or distribute without written permission.

5. Timing and Rhythm • Rhythm forms foundation of timing upon which we use timing to ultimately organize and sequence • Sequencing alone is not enough – must be done in the context of timing • Increasingly implicated in cognitive processing disorders (Harnadek & Rourke, 1994) • Language and language disabilities (Merzenich et al., 1996) Do not use or distribute without written permission.

6. Brain Regions activated • Primary motor cortex (MI) controls voluntary movements, through network distribution, not discrete – capable of modification – plasticity • Intrinsic horizontal connections • Bilateral primary sensori-motor area, left ventral pre-motor cortex • Posterior supplementary motor area • Right superior part of cerebellum • Left Putamen • Brodman’s area 6 – right dorsal pre-motor cortex, right Precuneus, Brodman area 7 – activation increased with complexity • Also Cerebellar Vermis and Left Thalamus. • Left Inferior Parietal Lobe decreases (area associated with short-term phonological storage) Do not use or distribute without written permission.

7. Primitive Reflexes • Symmetrical Tonic Neck Reflex (STNR) • Bilateral patterns of body movement • Information processing right and left hemispheres • Crawling on all fours in cross-lateral style • Calming down the body motion activity, freezing reaction, activate perception of seeing and hearing • Saccadic Eye Movement Do not use or distribute without written permission.

8. Assymetrical Tonic Neck Reflex (ATNR) • Supports one-sided and asymmetrical, cross lateral motor coordination within Right-Left Motor Coordination System • Crossing midline • Turning to the sides • Prepares infant for future transitional movements • Motor-proprioceptive-vestibular system • Mono-auditory perception • Auditory-vision coordination • Auditory Memory • Crossing midline – activation of auditory-vision midfield • Binaural hearing and listening, binocular vision. Do not use or distribute without written permission.

9. Developmental Features • 1 to 3 months = swiping • 3 to 6 months • hands to midline, proximal stability, hands to mouth; beginning purposeful grasp • 3 to 5 months • symmetrical bilateral reach leading to asymmetrical reach; controlled • 6 to 12 months • Orientation to external world • Mobility allows development of spatial awareness and body scheme • Anticipation of events • Free hands allow deliberate • Actions on the world • Imitating actions Do not use or distribute without written permission.

10. Anatomy of the Ear Do not use or distribute without written permission.

11. Receptors and Transduction • Semicircular Canals • Otolith organs: utricle and saccule • Endolymph of auditory system moves freely between auditory and vestibular systems • Otolith organs – static functions; position of head, body in space, and control of posture • Semicircular canals – dynamic functions; respond to movement of head in space • Neurotransmitters could be excitatory (afferent fibers) and inhibitory (efferent fibers) in function Do not use or distribute without written permission.

12. Utricule • In upright position hair cells of utricle are oriented to the horizontal plane • When head tilts or moves linear stimulus detection occurs with neural firing as result • Hair cells in each quadrant of the utricle are systematically oriented in different directions • Allows for detecting head movement in 3 orthogonal planes of space: linear, sustained and low frequency stimuli (from auditory) Do not use or distribute without written permission.

13. Saccule • Less well understood • Some thoughts: vertical accelerometer, vibratory receptor • Kandell (2000) noted influence of gravity as most important, also anterior-posterior movement in relationship with acoustic information • Works together with utricle in head tilt and respond to linear movement • Critical to the maintenance of upright posture and equilibrium. Do not use or distribute without written permission.

14. Semicircular Canals • Detects changes in the direction and rate of angular acceleration or deceleration of the head • Angular acceleration – rotary head movements (spinning, head nodding) • Head tilted forward 30 degrees – horizontal canal • Anterior and posterior canals are vertical and oriented at right angles to each other Do not use or distribute without written permission.

15. Canals are paired structures • Movement in one direction leads to movement of the endolymph in one direction in one ear and in opposite direction in the other ear • Bending of hair cells: depolarization or hyperpolarization • Information from both ears to the brain is different • Depolarization in one ear is excitatory and hyperpolarization is inhibitory Do not use or distribute without written permission.

16. Adds to 3-dimensional space • Most efficient stimuli in semicircular canals are angular, transient (short-term) and fast (high frequency) head movements of at least 2 degrees by second • When head moves at slower speeds, all haircells move at same speed of the head • Always activity in vestibular nerve, activation increases reception Do not use or distribute without written permission.

17. Vestibular Nuclei in Brainstem • 4: lateral, medial, superior, and inferior • Each receives ipsilateral and contralateral input • Receives input from spinal cord, cerebellum, and visual system • Organization of these inputs allows for detection of direction and speed of head movement and position of the head relative to gravity Do not use or distribute without written permission.

18. From Visual • Relayed through the inferior olive and cerebellum • Generating eye movements • Postural response to vision, particularly to peripheral vision, is very rapid – observed in standing balance tasks as well as walking heel to toe in a straight line • Better with eyes open than eyes closed • Response to movement in visual surround indicates that infants use optic flow to control their posture • Older children inhibit postural response better, swayed, but did not fall • As balance control and muscletone develop, older children appear to compensate for optic flow Do not use or distribute without written permission.

19. Balance may be complex • Balance is an effective function of the vestibular system, an ability to hold a position stationary against gravity • Balance is also affected by depth perception difficulties – when the two eyes are not working together in harmony, causing suppression of the information of one eye, which ultimately influences depth perception. Do not use or distribute without written permission.

20. Projections • Direct connections: vestibular nuclei, cerebellum, oculomotor nuclei, and spinal cord • Also to Reticular Activating System (RAS), the thalamus • And the cortex – frontal lobe or anterior portion of the parietal lobe • Each connection has a unique function Do not use or distribute without written permission.

21. Vestibular and Cerebellum • The only sensory system with direct connections to the cerebellum • Direct projections to the cerebellum and in turn direct projections from the cerebellum to the vestibular nuclei • Important for ongoing control of eye and head movement as well as posture Do not use or distribute without written permission.

22. Postural background movements • When we reach for something, or push-pull with our hands, our trunk and legs automatically adjust themselves so that our arms do their job efficiently • Entire body must sense and move as a whole unit if the hands and arms are going to do anything well. Do not use or distribute without written permission.

23. Cocontraction • To hold the head steady and move it efficiently, all the muscles around the neck must be able to contract at the same time • Function is holding the body steady so that it will not easily be pulled and pushed off balance Do not use or distribute without written permission.

24. Protective Extension • Vestibular and proprioceptive information interact to warn the brain of possible injury to the body when it is about to fall. • As approach the ground in a fall, the brain sends out messages that extend or straighten the arms • The extension stops the fall and protects the face and the chest Do not use or distribute without written permission.

25. Vestibular and Oculomotor Nuclei • CNIII (ocularmotor), CNIV (trochlear), and VI (abducens) • Fixing eyes as the head and body move – ongoing stable visual image • Compensatory – equal in direction and opposite in direction to the head movement perceived by the vestibular system • Head movement activates vestibular-ocular reflex (VOR) to stabilize visual field, even with body moving Do not use or distribute without written permission.

26. Nystagmus • Specialized VOR • Head moves – VOR allow eyes to remain fixed on an object in space • With continued angular movement of the head the eyes reach the end of their range of motion • At this point the eyes spring back to their central position and the process begins again • Initial phase – slow phase • Fast phase when eye returns to central location (after which nystagmus is named) Do not use or distribute without written permission.

27. Acting on antigravity extensor muscles • Utricular inputs – limb and upper trunk – ipsilateral facilitation of extensor muscles and inhibition of flexor muscles • Semicircular inputs – bilateral facilitation of neck and upper trunk muscles • Utricle responses – sustained postural responses • Semicircular canal responses – phasic equilibrium responses Do not use or distribute without written permission.

28. Influence of transient or angular head movements stimulating semicircular canals in phasic • Stabilization of the head and upper trunk in the upright position • Extension of the weightbearing limbs on the side toward which the individual is rotating or tilting (downhill side) • Flexion of the weightbearing limbs on contralateral side • Compensatory abduction and extension of non-weightbearing limbs Do not use or distribute without written permission.

29. Sustained head tilt or linear head movements stimulate the utricle in tonic (maintained) • Extension of downhill weight-bearing limbs (support reaction) • Flexion of uphill weight-bearing limbs • Compensatory abduction and extension of non-weight-bearing limbs • Stabilization of the head and upper trunk in the upright position Do not use or distribute without written permission.

30. What does this mean with regards to function? • Goal: tonic postural support reactions – intervention should focus on utricular stimulation • Goal: more phasic or transient postural reactions – stimulate semicircular canals Do not use or distribute without written permission.

31. More connections • Overlap with somatosensory system in thalamus • Intraparietal Sulcus – head movements, especially associated with dizziness – overlap between vestibular, visual and proprioception – perception of motion and spatial orientation Do not use or distribute without written permission.

32. Vestibular and Proprioceptive System • Jointly contribute to the perception of active movement; development of body scheme • Also involved in the use of postural responses, especially those of the extensor muscles • Role of proprioception system: provide the motor system with clearly defined map of the external environment and the body • Also may play a role in programming and planning of bilateral projected action sequences Do not use or distribute without written permission.

33. Nashner (1982) • Inputs from the vestibular system could be used to resolve vestibular-visual-somatosensory conflicts • Vestibular-proprioceptive system work together to provide a stable frame of reference against which other sensory inputs were interpreted Do not use or distribute without written permission.

34. Vestibular, Proprioception and Vision • Subjective awareness and coordination of movement of the head in space • Postural tone and equilibrium • Coordination of the eyes, head and body, and stabilization of the eyes in space during head movements (compensatory eye movements) Do not use or distribute without written permission.

35. Signs of Vestibular Dysfunction / Functional Implications*not an exhaustive list • difficulty with attention / sitting still / frequently on the go • difficulty following instructions/directions  • emotional insecurity/dysregulation • difficulty with coordination; clumsy, collides with objects/people • poor postural control (i.e. falls from chair) • poor core muscle strength • poor eye-hand/ eye-foot coordination • poor balance and unsteady when walking on uneven ground or surfaces • poor body awareness • feels insecure with movement (‘very cautious’) • panics when held up in the air/ upside-down/or spun • dislikes head tilting backwards (i.e. in bathtub to wash hair) Do not use or distribute without written permission.

36. Signs of Vestibular Dysfunction / Functional Implications Continued • refuses to play on playground equipment or avoids sports • reaches out with hands from furniture piece to furniture piece, or, walks down hallways with hands or fingers constantly running against wall as a stabilizer • afraid to come DOWN stairs • observed crouching down to the ground to keep from falling in seemingly non-threatening situations • seeks intense movement of all kinds (running, spinning, swinging  • extreme reactions when feet are ‘off the ground’ or with any kind of height  • may seem oblivious to risks of heights and moving equipment (i.e. ‘no fear’) • doesn’t get dizzy even with excessive spinning or rotation • gets overly dizzy with the slightest spin or rotary movement • becomes sick easily in cars, elevators, carnival rides • bilateral integration difficulties - hard to get both sides of body working together efficiently • does not show hand preference by age 3 ; inconsistent crossing or midline (ie. switches hands/ “ambidextrous”) Do not use or distribute without written permission.

37. Signs of Proprioceptive Dysfunction / Functional Implications • Poor motor planning/ poor body awareness, position in space • Not reaching motor milestones on schedule • Walks on tiptoes • Chews frequently on shirt, cuffs, strings, pencils, toys, and gum • Seems to have weak muscles, tires easily, poor endurance • Poor posture; slumps; sits on edge of chair with foot for support • Continually seeks out all types of movement activities/ jumping/ crashing/bumping • Need to be hugged and held tightly or snugly (or the opposite - avoidance of hugs or touch) • Bilateral coordination difficulties/ clumsiness/poor sequencing, timing, rhythm • Movements are not smooth and coordinated; may be stiff/robotic/or floppy • Poor dynamic  balance  • Feels heavier than he/she looks Do not use or distribute without written permission.

38. Signs of Proprioceptive Dysfunction / Functional Implications Continued • Craves activities such as wrestling, and ‘rough housing’ • Holds crayons/pencils too tight or too loose • Difficulty following motor actions or following instructions for physical movement • Looks with eyes to make body position adjustments • Accident-prone; always falling; bruising; stubbing, or banging parts of body • Prefers to be controlling of a game to reduce risk of having to imitate actions, follow instructions, rules of game, etc • Avoids sports or related activities requiring timing (ie. soccer) • Difficulty judging force or distance - frequent hitting/pushing incidents • Difficulty grading movements --“too hard or too soft” - stamps or slaps feet with walking Do not use or distribute without written permission.

39. Vestibular – Bilateral Disorder • Generally considered typically developing until they enter school and have difficulty with academics • May be confused with dyslexia or attention problems • Average or above average IQ, but cannot use in learning to read or compute Do not use or distribute without written permission.

40. Bilateral Integration • Poor integration of two sides of the body • Difficulty coordinating left and right hands • Easily confused by directions or instructions • Hands and feet may not work well together • Interferes with inter-hemispheric specialization Do not use or distribute without written permission.

41. Vestibular-Language Disorders • Vestibular system major organizer of sensation and contributes to the development of word understanding and speech • Children with problems in articulation, speech and language – short duration of post rotary nystagmus (PRN) • Difficulties in symbolic use of language – lowest duration of nystagmus • Vestibular input facilitates vocalization Do not use or distribute without written permission.

42. Influence on Emotional Development and Behavior • “If the child’s relationship to the earth is not secure, then all other relationships fail to develop optimally” • Limbic system is part of cerebral hemispheres that generates emotionally based behavior • For emotions to be “balanced” the limbic system must receive well modulated input from all the senses • Experiments: without vestibular information in infancy, animals grow up to be hostile, aggressive or withdrawn • Rocking the baby to calm • Sports activities can be emotionally gratifying • “Lost in space" – cannot follow inner drive out of fear of what may happen to them – misses sensori-motor experiences Do not use or distribute without written permission.

43. Influence on Digestive Tract • Motion sickness – nausea – brain gets too much information it cannot organize effective response • Literally stops the movement of food through the digestive tract – nausea, queasiness • Frequent difficulties with bowel and bladder control Do not use or distribute without written permission.

44. Influence on Academics • Seated attention • Balancing environment with speaker / teacher • Reading requires visual in motion • Writing requires postural control from core Do not use or distribute without written permission.

45. 9 Lacrue Avenue, Suite 103 Glen Mills, PA 19342 Maude Le Roux, OTR/L, SIPT, IMC Website www.atotalapproach.com Facebook https://www.facebook.com/ATAMaudeLerouxOT/ LinkedIn https://www.linkedin.com/company/a-total-approach Blog http://www.maude-leroux.com/ Do not use or distribute without written permission.

46. Book Resources Ayres, A. Jean, and Jeff Robbins. Sensory Integration and the Child: Understanding Hidden Sensory Challenges. Los Angeles, CA: WPS, 2005. Print. Brody, Viola A. The Dialogue of Touch: Developmental Play Therapy. Northvale, NJ: J. Aronson, 1997. Print. Bundy, Anita C., Shelly Lane, and Elizabeth A. Murray. Sensory Integration: Theory and Practice. Second ed. Philadelphia: F.A. Davis, 2002. Print. Lane, Shelly, and Anita C. Bundy. Kids Can Be Kids: A Childhood Occupations Approach. Philadelphia: F.A. Davis, 2012. Print. Masgutova, Svetlana, and Denis Masgutov. Tactile Integration: Masgutova Method of Neurosensorimotor Facilitation. Print. Montagu, Ashley. Touching: The Human Significance of the Skin. New York: Columbia UP, 1971. Print. Schaaf, Roseann C., and Zoe Mailloux. Clinician's Guide for Implementing Ayres Sensory Integration: Promoting Participation for Children with Autism. Bethesda, MD: American Occupational Therapy Association, 2015. Print. Do not use or distribute without written permission.