Swallowing and the Magic Tambourine
A sensory integration
By Karen E. Frank, MA, CCC-SLP
SENSORY INTEGRATION IS THE ABILITY TO TAKE in, sort out, and connect information from the world around us. According to sensory integration theory, there are three essential systems that we rely on to organize sensory information: vestibular, proprioceptive and tactile. These three systems need to work together efficiently so that we may function to our fullest potential in our environment.
Sensory disorders are numerous, e.g., gravitational insecurity, tactile defensiveness, visual discrimination problems, etc. Frequently they are encountered among individuals--both children and adults--with developmental disabilities.
Consequently, it is becoming increasingly recognized that therapists working with the developmentally disabled population need to be trained in sensory integration theory so that they can evaluate sensory dysfunction appropriately. Equally important is the need to be able to incorporate sensory integration techniques into practical treatment strategies.
Therapists with any experience in this area know this can be extremely challenging, given some of the complex scenarios that can present themselves when working with individuals who are multiply handicapped. The following case illustrates a unique set of circumstances for the application of sensory integration theory and treatment.
A 65 year-old man with a primary diagnosis of profound mental retardation and secondary diagnoses of cerebral palsy, legal blindness and seizure disorder has had a long-standing history of seizures, requiring ongoing medication adjustments. With advancing age deterioration in a number of areas had been noted, including level of alertness, mobility and swallowing.
More specifically in the area of swallowing, a progressive decline in his ability to handle thin fluids was documented over a four-year period. This eventually required that all fluids be thickened to a pudding consistency. In addition, all solid food needed to be presented in a puree consistency the thickness of pudding.
With careful management of food and fluid consistencies, this gentleman was able to remain eating orally and suffered little or no respiratory difficulties despite his declining status.
However, recently staff began to report an increase in coughing episodes at mealtime. Reports varied as to whether they were occurring before, during or after meals. Staff comments also were inconsistent concerning what type of foods possibly were causing the coughing, i.e., pudding vs. vegetables.
This prompted a re-evaluation of swallowing status. The result of the evaluation indicated that the consistency or type of food was not necessarily the problem. An unusual behavior had emerged at mealtime that was felt to be interrupting the swallowing process.
The client was exhibiting a repetitive sputtering noise produced at the lips, something akin to "blowing raspberries." The behavior was not new to this gentleman, as he often had displayed it in the past when left unoccupied for any length of time. It was considered to be self-stimulatory in nature and was accompanied by other repetitive behaviors, such as tapping on his wheelchair tray. This behavior was not new to mealtime either.
Occasionally in the past it would become problematic, since staff typically would get showered with secretions as they assisted with feeding. However, a verbal redirection of "no spitting" or "swallow please" generally would alleviate the behavior. The staff also became very adept at quickly diverting a spray with a large napkin when necessary.
Unfortunately, the behavior could not as easily be redirected in this more recent development. It became so frequent during eating that coughing and/or gagging episodes would ensue.
During evaluation sessions, therapists observed this individual begin to exhibit the behavior so quickly after the spoon left his mouth that it was nearly impossible to swallow effectively. In addition, this often left the neglected food or fluid bolus at risk for premature spillage. It was no wonder that staff were noting an increase in coughing episodes as the oral mechanism repeatedly was engaged in the counterproductive behavior.
Given the medical status of this person, it was imperative that a solution to this problem be found if he was to continue to eat orally. Therapists began an intensive diagnostic process to determine a way to eliminate or redirect this behavior.
As was stated earlier, verbal redirection was no longer effective. Physical diversions such as tapping a napkin on the lips or prolonging spoon placement to disrupt the behavior also were unsuccessful. Jaw and lip control techniques met with no noticeable improvement. In fact, efforts to interfere with the behavior tended to increase the frequency and/or severity, since this person would become quite agitated when these attempts were made.
After exhausting all traditional avenues, a rather unique strategy was attempted based on sensory integration theory.
In the past, the staff had discovered, this gentleman tended to engage in this behavior when left unoccupied for any length of time. They offered him a tambourine or other hand-held device to shake. In most instances he would stop the sputtering while shaking the item.
Consequently, therapists decided to introduce this activity at mealtime.
While the activity was not unique, the application certainly was. In the case of this particular gentleman, the activity of shaking the tambourine was felt to meet vestibular, proprioceptive and tactile needs. The effect of these types of input appear to have a modulating influence, resulting in calming of the nonproductive behavior (i.e., blowing raspberries), and an organizational effect, which enhances swallowing activity (i.e., sensory input to increase arousal, attention/focus and planning).
The biggest obstacle was finding an appropriate tambourine to use at mealtime. The one used at the residence was rather large and extremely noisy. While it was appropriate for a musical jamboree, it was not exactly conducive to a quiet, relaxed dining environment. Thanks to an offering by a local food chain, a small child's tambourine that produced a light, pleasant noise when shaken became the "magic" that turned this case around.
When given the tambourine during meals, the client immediately began to shake it instead of engaging in the sputtering behavior. Also, while shaking the tambourine, he was more likely to reorganize for a second swallow. This was an additional benefit since this gentleman tended to pool in the vallecula and pyriform sinus area. While he was encouraged to swallow a second time to clear in the past, he was not always consistently able to do so upon command.
This is an excellent example of how a sensory integration approach was found to be beneficial for an older, severely involved person who is developmentally disabled. To date, this gentleman continues to be fed orally, and this strategy remains as effective for him as when it was first introduced in the spring of 1997.
Karen Frank is on staff at United Cerebral Palsy and Handicapped Persons Association of the Utica Area, Inc., Schoonmaker Day Treatment Facility, 12592 Potato Hill Rd., Boonville, NY 13309-9331.