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The adult psychiatric sensory integration evaluation
Covers sensory & motor responses; developmental history; & various neurologic soft signs Various evaluation procedures normed for children are used informally by clinicians for adult clients with brain damage
San Diego Veteran’s Administration Medical Center 15 clients with chronic schizophrenia, paranoid schizophrenia, & hyperkinetic adult syndrome Tested both on & off medications SBC evaluation & 11 subtests from the Southern California Sensory Integration Tests by Ayres Rationale:
To have an objective numerical score of a patient’s ability to perform at any given point in time When reliability, validity & norms are established, it is possible to objectively evaluate:
An individual client over time The effects of medication, or other forms of treatment, both acutely & over time Groups of clients by diagnosis or by other criteria
Benefits to the client:
The physician & treatment team have a better understanding of their client’s physical ability to interact with his environment The client himself better understands his physical abilities & disabilities An increased understanding of the neurologic components of psychiatric
Focuses primarily on measurable perceptual & motor changes in schizophrenia Many methodological & technical flaws in the reported results. Any research on perception is as complicated as the perceptual response itself
Literature review - neurochemistry
Neuroregulators are thought to be primarily under genetic control but responsive to stress. Given enough of a specific stress, the neurochemical mechanisms are altered, initiating changes in perception & behavioral responses which are then labeled to as a psychiatric disorder. Disordered dopamine transmission in schizophrenia Lowered MAO platelet activity & a corresponding low platelet activity in 1st degree relatives Reported correlation between lowered MAO inhibitors, platelet activity, increased incidence of abnormal EEG, & presence of auditory hallucinations High level of endorphins in schizophrenia The report or an exciting finding & then difficulty in replicating the results has plagued schizophrenia research
Literature review – vestibular system
Leach study – schizophrenic groups showed diminished reactivity, with the greatest deficits occurring under conditions of weak stimulation, & were relatively more normal with increased stimulation. Some studies report transitory hyporeactivity Some studies, acute & chronic schizophrenic clients demonstrate normal vestibular responses Holtzman observed eye tracking dysfunctions in schizophrenic patients & their relatives. The vestibular system plays a significant role in perception, & is intricately interconnected to many brain structures, some of which are known to be affected by dopamine More research needs to be done to clarify which subtypes, in any, of schizophrenic clients show vestibular involvement.
Literature review – psychomotility
Involves processing information & responding to stimulation Psychomotor changes parallel the course of clinical improvement, & clients responding favorably to tranquilizing drugs do significantly better on psychomotor tests before & after drug administration Weaver & Brooks – high association between good or poor psychomotor performance & release from the hospital; 75% accurate prediction of patient outcome was made based on psychomotor
Literature review – body image
Almost all reports of body image refer to figure drawings Despite problems of validity & reliability, body image is included because it tells so much about the quality of the client’s perception of himself.
Literature review – anatomical changes
Marsden reports cerebral atrophy & cognitive impairment observed Johnstone – cerebral ventricular size is highly significant in relation to cognitive impairment Other anatomical changes:
Motor end plate alterations or branching & sprouting of nerve twigs, abnormal electromyograms, Increased electrical activity of skeletal muscles at rest Increased incidence of morphological
Literature review – laterality
Gur study – left sidedness on laterality scores Flor-Henry – increased EEG foci in the left temporal lobe of schizophrenics Other researchers found less eye & hand congruence in schizophrenics than normals
Literature review – abnormal movements
Movement disorders in schizophrenia have been reported before the advent of drugs, & includes stereotypic mannerisms, hypo & hyperkinesia Also involuntary ocular movements (deviant eye tracking, gaze disturbance, altered blink rates, eye deviation, abnormal saccadic movements & failure to converge) Can occur from side effects of neuroleptic medication due to toxicity, hypersensitivity, & long term use Can be affected by a subject’s anxiety, by interpersonal contact, & by physical contact with persons Dyskinesias are involuntary movements & are thought to occur in older psychotic patients in whom long term treatment with the anti-psychotic drugs of phenothiazine & butyrohenone groups has occurred.
Literature review – neurologic soft signs Soft signs are chronic, & non-life threatening & can refer to any neurologic deviation: motor, sensory, or integrative Manifestations:
Delay in reaching developmental milestones Difficulty in acquiring simple athletic skills Learning problems Organic indicators on mental status exams
Scoring is based on a 0-3 scale (0 is normal, 1,2,3 are the degrees of divergence from normal) It is an evaluation tool consisting of definite procedures, observations, scoring, work sheets,& summary sheets Dominance
Eye, hand & foot dominance
Eye: subject asked to look through a paper tube at an object on the wall; paper tube is replaced by a piece of cardboard which has a ¼ inch hole in its center; key ring Hand: write his name on top of the paper Foot: asked to hop on 1 foot 3x; kick softly a ball in front of
Stand in relaxed position; therapist runs the fingers down the spine for lordosis, kyphosis, scoliosis, asymmetrical posture, inward rotation of the shoulders
Rotate head first clockwise, then counter-clockwise; smooth or jerky? Full ROM?
Walk away from the therapist & return; associated arm movements? Shuffling?
Place hands palms down, and then turn palms up to look for abnormal hand structure
Fine motor control
Use of tapping board to tap as fast as he can using the index finger of the dominant & non-dominant hands
Alternately pronates & supinates both hands simultaneously for 10 seconds; smoothness & synchronization of movement?
Touch each finger of one hand to the thumb; smoothness of movement? Speed? Coordination? Ability to perform without visual cues?
Visually track a penlight without moving the head
Bilateral coordination – upper extremity
Draw two circles simultaneously on a blackboard, one with each hand; eye-hand coordination? Ability to coordinate the motor use of both Ues?
Cross the midline
Draws a line from his left to his right on the blackboard & retraces it; subject crosses? Avoids crossing? Line irregular?
Stability of the upper extremity
Clasp his hands in front of his chest, therapist places one hand above & one hand below the subject’s hands, then pushes & pulls; keep hands within 8 inches of his chest?
Stability of the trunk
Stand & hold his body still, he is then pushed FW, side to side, BW; ability to cocontract trunk? Steps to avoid losing his balance? Excessive fluidity?
Test for balance; walk a line on the floor without looking at the line, then to retrace
Cross his arms over his chest & place his feet in the tandem walking position, subject holds this position for 30 seconds with eyes open, 30 seconds with eyes closed
Stand with both arms extended at shoulder height with fingers extended & slightly apart; with eyes closed, he is asked to hold position for 30 seconds; movements exceed 3 inches?
Same as used to test overflow movements; First rotates subject’s head to the right, then to the left; trunk & arms tend to align with the head?
Subject’s ability to rotate his trunk; roll on a mat to his left, then to his right
Asymmetrical tonic neck reflex
Quadruped position, making sure that his elbows are clearly visible; head turned to the right, held for 5 seconds, then turned to the left & held for 5 more seconds
Symmetrical tonic neck reflex
Examiner extends subject’s neck & holds it for 5 seconds, then lowers the head towards the chest & holds it for 5 more seconds
Tonic labyrinthine reflex
Pivot prone position & hold it for 30 seconds
Upsets balance by pushing him to the front & to the sides, & by pulling him backwards; reaction slow? Adequate? Absent?
Wear a safety belt, to straddle an inflatable, & to rock side to side without holding on to the inflatable; right his head & trunk when rocking? Ease to do the task? Balance?
Draw a complete picture of a person; size of the drawing? Anatomy indicators?
2 types: those that show upon activation & those that show spontaneously
Automatic obedience – extends the subject’s arm over his head, holding it for 30 seconds Cogwheel rigidity – flexing the subject’s arm & feeling for intermittent contraction of either biceps or triceps Tongue protrusion – protrude his tongue, timing it for 30 seconds
Self-reported childhood history
Developmental history is taken to see if the subject has had any
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