September 2, 2013
Connecting the dots
Recent reading on the diaphragm is helping me to connect the dots regarding the vestibular system and postural control. I thought I would share my thoughts and my reading list with you this month.
*The vestibular system is a powerhouse in the brain, influencing many things from the perception of movement to emotional regulation
*The vestibular system modulates the sensitivity of every other sensory system. New research even indicates that the vestibular system directly reduces the acute perception of pain!
*The vestibular system is intimately connected with the visual system by the Vestibulocular Reflex (VOR) which serves to keep the visual image in the middle of the visual field as the head is moving
*The vestibular system participates in the regulation of the activity of the respiratory diaphragm. This makes sense if we think about the fact that gravity and movement impact how the diaphragm needs to work.
*The diaphragm is a crucial inner core muscle, which participates in anticipatory postural control
*Vestibular system dysfunction has also been implicated in low muscle tone
So,
It makes total sense that our children with low tone have difficulty with vestibular input/processing. These children also frequently have difficulties using functional vision for postural control. They also have poor activation of their respiratory diaphragm, and consequently the pelvic floor muscles (because these muscles work as a team). This results in upper chest or belly breathing (=diaphragmatic) patterns and poor pelvic stability. All of these combined manifest in poor posture and inefficient postural control which compromises balance, gross motor and fine motor function. They also impact phonation, my SLP friends inform me.
Given this information, we should be addressing the vestibular system as an integral part of treatment for improved postural control.
Practical App:
For a child who is hypo-responsive in their vestibular processing, try priming the vestibular system prior to balance training.
Before working on balance activities, have your client participate in movement that will activate their vestibular system. Find out what they like to do – swing, spin, jump, twirl, run, even nodding their head creates vestibular input. Engage them in that activity for a defined length of time. Start with brief vestibular activation (to ensure that the system does not move into overload) and pair it with work on balance training. You can gradually increase the length of time for vestibular preparation activities or repeat them within a session if they are well tolerated. And as always, pay attention to alignment. A rib cage that is not stacked over a neutral pelvis changes the resting length of the diaphragm as well as head position and both of these impact negatively on vestibular system function. Remember, it’s all connected!
Further reading:
Bordoni B, Zanier E. Anatomic connections of the diaphragm: influence of respiration on the body system. 2013 J Multidiscip Healthc. 6: 281-91.
Ferrè EF. Balancing the somatosensation. 2013 http://www.bodyinmind.org/balancing-the-somatosensation/
Gandevia SC, Butler JE, Hodges PW, Taylor JL. Balancing acts: respiratory sensations, motor control and human posture. 2002 Clin Exp Pharmacol Physiol. 29:118-21.
Khan S, Chang R. Anatomy of the vestibular system: a review. 2013 Neurorehabil. 32:437-43.
Niedrignhaus M, Jackson PG, Evan STR, Verbalis JG, Gillis RA, Sahibzada N. Dorsal motor nucleus of the vagus: a site for evoking simultaneous changes in crural diaphragm activity, lower eosophageal sphincter pressure and fundus tone. 2008 Am J Physiol Integr Comp Physiol. 294: R121-31.
Yates BJ, Billig I, Cotter LA, Mori RL, Card JP. Role of the vestibular system in regulating respiratory muscle activity during movement. 2002 Clin Exp Pharmacol Physiol. 29: 112-7.
Young RL, Page AJ, Cooper NJ, Frisby CL, Blackshaw LA. Sensory and motor innervation of the crural diaphragm by the vagus nerves. 2010 Gastroenterol. 138: 1091-1101
Zur O, Ronen A, Melzer I, Carmeli E. Vestibulo-ocular response and balance control in children and young adults with mild-to-moderate intellectual and developmental disability: A pilot study. 2012 Res Dev Disabil. 34: 1951-7.
Great post – I have to admit I tend to think more in terms of proprioceptive input than vestibular so your post has widened my perspective a bit. I love the good ol’ physio ball this. I often start a session with kids bouncing on the giant (120cm) ball in good alignment – it’s fun but controlled – Mind you I was always thinking more proprioceptive input – but it’s great vestibular input too on reflection 🙂 Jumping on a trampoline and bashing the physio ball away at the same time is another one I like to use to get active abs with propriceptive (and now thinking vestibular) input – thanks
I agree the physio ball addresses both sensory systems so that’s a bonus! I am careful about alignment on the ball though, because without the rib cage stacked over top of a neutral pelvis we will have more activation of superficial than deep abdominals. Thanks for sharing 🙂
My child has ADHD and has a lot of difficulty with emotional self-control, especially with angry, frustrated, or hurt feelings. Sometimes the only way to bring my child “back down” is with swinging, bicycling, or running. Can you tell me more about this statement from your article? “*The vestibular system is a powerhouse in the brain, influencing many things from the perception of movement to emotional regulation” Or direct me to where I can read more about it? Very interesting. And thank you so much for this post!
Thank you for sharing your strategies that help your child. The vestibular system modulates every other sensory system in the body. It modulates the emotional system (the limbic system) and the arousal system (the reticular activating system). So movement helps to regulate our emotions! My blog entitled Jeopardy talks a little more about it as well. There are two books I might recommend. They are “The Out-of-Sync Child” and “Sensational Kids”. Both deal with children with Sensory Processing Disorder however sections of each book also discuss ADHD. I would also suggest looking for an Occupational Therapist who has training in both sensory processing and emotional self-regulation. A thorough assessment could help implement strategies pro-actively so that you can help your child maintain emotional balance.
Thank you for responding. I have to smile to myself because The Out-of-Sync Child is one of the first books I read as I tried to figure out what was happening with my child (pre-diagnosis). While it didn’t describe my child to a T, very much of it was helpful and made sense. I’ll have to recheck that book and find the other one you mention. Oddly enough our younger child’s speech pathologists had a LOT of helpful information and ideas on how to help the older sibling’s behaviors. I’m glad I found your blog through this particular article someone pinned on Pinterest. Thank you so much!
Glad to be of some help!
Another great read. I had not heard before that the vestibular system reduces the perception of pain. Brings so many questions to mind – do individuals with under responsive vestibular systems have decreased pain perception and over responsive have increased pain perception? In my experience, children with under responsive propriocpetive systems have decreased pain perception. Never really thought about with the vestibular system though.
Very good tip about maintaining proper alignment at all times.
For the practical application, you suggest prior to balance activities. Are you suggesting more benefits before balance or just using it as an example? I would think before any motor skill training it would be beneficial. Thanks for a jam packed post that makes me think yet again!
Thanks Margaret. Yes, I used balance activities as an easy example but in clinical practice I always prep the vestibular system before movement for children who are displaying a deficit in that system or who have low tone or need assistance with being ready for movement. The information regarding modulation of pain and the vestibular system is just starting to be discussed in chronic pain literature and I have not read all of those references; we don’t know how it relates to our paediatric clients but I agree, I would love to know those answers.
I frequently tell people (clients and co-workers alike) that pediatric PTs should not just leave sensory processing to OTs, using the example of balance – a combination of three sensory systems (visual, vestibular and proprioceptive). Thank you so very much for sharing your sources! Can’t wait to track them down.
Thanks Karen, I totally agree. Postural control (and indeed any motor event) is a sensory event first. We can’t overlook that knowledge base in our theory or practice!!
I totally agree, pediatric PTs should be addressing sensory processing. It is frequently overlooked as an area for us to address but has been in the ‘literature’ for quite some time (Martin 1992). Julia
Let’s keep getting the word out Julia – any PT who is working on balance needs to consider the sensory processing required!