1. Multisensory Training Laura Morris, P.T. University of Pittsburgh Medical Center

2. Session Objectives  Be able to describe how each sensory system contributes to postural control in different sensory environments  Be able to understand how the type of sensory system impairment will affect exercise selection and progression  Be able to identify the rationale behind the selection of exercises for stimulating each of the three sensory systems (visual, somatosensory, vestibular)

3. Sensory Systems ENVIRONMENTAL Respond to ENVIRONMENTAL Manipulations

4. Task Demands Environment Individual Capabilities Surface Type Visual Flow Seated Standing Moving Single Multiple Strength ROM Sensory Loss Cognition Lighting

5. Multisensory Training  Successful sensory input depends on:  Amount and quality of peripheral sensory receptors  Integration and organization of info by the central nervous system

6. Peripheral Sensation  Visual  Vestibular  Somatosensory  ALL degrade with the aging process...

7. How do we survive with such degrading sensory systems??!  Compensate for gradual changes as we age  Usually don’t develop problems until a disease process is added to the mix

8. Sensory Hierarchy: Vision  Gives information about head/eye position relative to surrounding environment  Sensitive but slower than somatosensation  Favored under stable surround but unstable surfaces

9. Sensory Hierarchy: Somatosensation  Measures leg/foot position relative to the surface  Fastest and most sensitive to balance disturbance  Favored under fixed surface conditions with limited vision

10. Sensory Hierarchy: Vestibular  Gives information about head position relative to gravity and inertial space  Fast but less sensitive to balance disturbances  Essential when vision is absent and surface is unstable

11. Optimize function compensating Optimize function of sensory systems while compensating for permanent damage Training Rationale and Goal:

12. Training Principles:  Optimize function by Stimulating or Forcing the use of sensory systems that are intact or when impairment is temporary  Compensate for sensory impairments that are permanent or progressive  Macular degeneration  Diabetic Neuropathy

13. Training Principles: ENVIRONMENT  Sensory Systems respond to changes in the ENVIRONMENT  By limiting/removing environmental input to system, challenge remaining systems to work harder

14. Assessment through MCTSIB  Allows for identification of sensory impairments  Medical history will help determine permanence of impairment

15. Stimulate Somatosensory: Disadvantage Vision on Stable Surface Destabilize vision:  Eye/Head movement (ball tracking, reading)  Complex visual environment (grocery store, crowds)

16. Stimulate Somatosensory: Disadvantage Vision on Stable Surface Remove vision:  Eyes closed activities  Can progress via sunglasses, low light in room

17. Assessment through MCTSIB  Which condition assesses somatosensory input?

18. Stimulate Vision: Stimulate Vision: Disadvantage Somatosensory while emphasizing stable visual focus Moving surface for gait (treadmill, uneven surfaces)

19. Stimulate Vision: Stimulate Vision: Disadvantage Somatosensory while emphasizing stable visual focus Destabilize standing surface (compliant surfaces)

20. Assessment through MCTSIB  Which condition assesses visual input?

21. Stimulate Vestibular: Remove/disadvantage both Somatosensation and Vision  Destabilized vision with compliant surface Also head turning, reading, catching/tossing ball

22. Stimulate Vestibular: Remove/disadvantage both Somatosensory and Vision  Absent vision on compliant/moving surfaces Can progress via sunglasses, low light in room

23. Assessment through MCTSIB  Which condition assesses vestibular input?

24. Reminders...  It is important to know the health history of each participant avoid contraindicated activities  If a multisensory activity causes significant, unexpected dizziness: stop the activity and encourage the individual to contact their PCP

25. Reminders…  SAFETY FIRST  Participants may be able to perform advanced activities in one area but not another due to different capabilities of each sensory system

26. Eye-Head Coordination  Designed to improve the ability for: Eyes alone to focus on moving object Eyes and head together to focus on moving object

27. Eye-Head Coordination  Designed to improve the ability for: Eyes to move quickly from one object to another without losing focus Eyes to focus on an object while the head is moving (gaze stabilization)

28. Eye-Head Coordination  Necessary for everyday life! Mall Grocery Store Crowds

29. Eye-Head Coordination  Be aware that these exercises can activate the vestibular system  If participant has an identified vestibular impairment or scores low on condition 4 of M-CTSIB, Level Two activities may be very challenging

30. Sensory Retraining Works! (Hu & Woollacott 1994)  Healthy older adults in controlled study  Group setting for sensory training program  Addressed all sensory conditions  Improved in postural stability during perturbations