Five Things every clinician and teacher should know for success in Vestibulotherapy

 #1 Vestibular dysfunction often remains unidentified and untreated.

To address the challenge of pediatric vestibular dysfunction often remaining unidentified and untreated (Li et al., 2014), measures of balance (Oyewumi et al. 2016); the examination of specific reflex responses linking inner ear (vestibular) function and eye movements such as post rotary nystagmus (Mulligan, 2011), and the subjective Bucket Test offer insight into vestibular functioning without the need for specialized equipment. Vestibular processing problems are commonly reported in children with neurodevelopmental disorders, such as developmental coordination disorder, autism, attention disorders, and learning disorders (Mulligan, 2011). The Vestibular Profile – Pediatric (VP-P) (Wall, 2022a) outlines this screening process and offers additional scaled scoring of learning attributes associated with vestibular functioning (Wall, 2022) that can track outcomes over time. The VP-P is available through a free download at vestibulotherapy.org

Fact # 2. Vestibulotherapy is founded on evidence from contemporary neuroscience.

For children who demonstrate delayed vestibular maturation or vestibular dysfunction, universal classroom-based interventions may positively impact their this sensory system so that learning and communication are supported through the promotion of myelination and neuroplasticity to areas involved in memory, sequencing, attention, and areas of executive functioning (Besnard, et al., 2016; Hitier et al., 2014; Kashfi et al., 2019; Lopez et al., 2020; Mast et al., 2014; Lotfi et al., 2017; Melo et al., 2019; Christy, 2019; Moossavi & Jafari, 2019).

In data collected from school-based research employing vestibulotherapy and the Vestibular Profile-Pediatric, students who demonstrated congenital vestibular dysfunction increased positive learning attributes at an increased frequency of 20-60% over baseline after an eight-week intervention of 20 minutes / day of each prescribed rotational activities and balance tasks (Wall, in process).

Fact # 3 The vestibular system supports learning by way of establishing spatial cognition through its modulation of information being processed to represent information in a specific spatial order, providing mental imagery, numeracy, and sequencing (Mast et al., 2014; Besnard, et al., 2016; Hitier et al., 2014).

Through this vestibular mediation of thought processes, it is theorized that outcomes of the intervention will include increased organization, sequencing, and ordinance that will positively impact the development of academic and communication skills in children ages 3-10 years who demonstrate delayed vestibular maturation .

FACT #4 The vestibular system’s role in perceptual and cognitive functions impacts learning, perceptual reasoning, and mental health (Hitier et al., 2014, Besnard, et al., 2016; Lotfi et al., 2017; Lopez, et al., 2020).

Despite efficient gains observed through motor learning theory, researchers found motor skills lacked opportunities for advancement due to deficits in body scheme, working memory, inhibition, spatial navigation, ideation, and poor timing and sequencing for more complex actions (Smits-Engelsman et al., 2018). Posture, movement experiences, and perception, collectively referred to as “embodiment” (Lopez et al., 2020) are supported by the vestibular system and provide foundations for complex movement, cognition, and social- emotional development through a sense of self (Besnard, et al., 2016; Lopez, et al., 2020; Mast et al., 2014). This self-perception provides orientation and navigation which consolidate into cognitive maps for future planning, sequencing, and complex behaviors.

Fact #5 Vestibular sensations mediate cognition.

 Vestibular sensations mediate cognitive performance by forming overlapping pathways between main memory centers (hippocampus, amygdala, thalamus, frontal cortex, and cerebellum) and vestibulo-cortical tracts for object recognition, inner speech, numerical cognition, spatial navigation, sequencing, attention, impulse control, future planning, ordinance, and a variety of mental activities including attributes of a theory of mind and executive function (Moossavi & Jafari, 2019; Hitier et al., 2014; Lane et al., 2019; Koziol, 2014; Besnard, et al., 2016; Lotfi et al., 2017).

Universal Intervention

I am excited to get back to supporting students in the classroom for a new school year! We concluded the last school year with a research project where teachers implemented contemporary neuroscience (Vestibulotherapy) into daily learning activities to impact learning outcomes. By providing this universally, students had frequent opportunities for neural plasticity and growth. Each classroom engaged in a total of 20 minutes/day intermittent activity-orientated interventions and 20-30- minutes of daily stability interventions embedded into classroom routines. The activity-orientated interventions replaced previously used brain breaks and incorporated content from math or language arts into the movement-based learning opportunities. Students reported high regards for movement-based learning. Teachers appreciated meaningful and engaging ways to incorporate the intervention into their classroom lessons. Above all, students benefitted with improved learning attributes including increased attention, organization, sequencing, and ordinance.

AOTA Inspire 2023

We had such a great visit to Kansas City for AOTA Inspire, national OT convention! It is such a pleasure and honor to connect with so many professionals who appreciate OT. If you visited my poster session, Thank you! I would love to connect with you again.

We are nearing the completion of a VestibulOTherapy research project where students in several 2nd and 3rd grade classrooms engaged in universal activities that totaled of 20 minutes vestibular based learning and 20 minutes of stability work each day. We have seen gains in attention, sequencing, organization, and overall classroom performance in all of the targeted students. Research interventions were based upon evidence and studies from my systematic review of vestibular studies from contemporary neuroscience. It has been so rewarding to see the evidence come to life as a universal classroom intervention!

It has also been a learning curve for promoting universal interventions. This process has been highly successful based upon professional relationships and collaborative learning outcomes over time.

Stay tuned for a research paper with all the interventions and results of our study! A preliminary paper has already been approved for publication and will be in OT Practice this year (date to be determined).

Movement based learning

As I prepare for the launch of a research project considering the impact of movement based learning and daily vestibular classroom interventions, I am challenged with perceiving how to orchestrate meaningful and successful classroom activities. As an OT, I often work with an individual or small group but teachers must command the attention and engagement of an entire classroom and they often do it beautifully and by no accident. I have made a list of potential activities and created a padlet of additional activities to generate my creativity for this project and would like to share them with you.

The guiding Vestibulotherapy Theory is based upon a systematic review: Given adequate vestibular activation through activity-orientated interventions (in an under-performing vestibular system), myelination and neuroplasticity propagate along learning pathways leading to greater neural connectivity and efficiency for sequencing, ordinance, attention, memory, body schema, spatial cognition, executive function, and interoception (Besnard, et al., 2016; de Wall, 2019; Hitier et al., 2014; Kashfi et al., 2019; Lopez et al., 2020; Mast et al., 2014; Melo et al., 2019; Moossavi & Jafari, 2019; Lotfi et al., 2017; Matuszkiewicz & Gałkowski, 2021). As a result of prescribed vestibular interventions and gained attributes supporting learning, students will experience increased academic performance.

1. Activity-orientated interventions:

a)     Visual-vestibular interventions. Students will participate in visual-vestibular activities (near-far accommodation, gaze, saccades, pursuits, and optokinetic exercises) embedded into daily learning activities. Examples include turn-and-touch, overhead / under passing, infinity pathways (Kawar, 2002), and other vestibular-visual games involving math facts, spelling, or sight words. 

b)     Vestibular interventions: Students will engage in child and classroom friendly interventions which activate multiple planes within the vestibular system encouraging adaptation and involving visual motor integration, eye-head coordination, fundamental motor skills, and perceptual-motor skills. Some examples include unicorn or elephant spelling, arrow mapping, helicopters, balloon games, turn and touch, over-head pass, S.M.A.R.T. activities (actg.org), catching / tossing, or twirling.

c)     Additional vestibular affordances may be encouraged in playground settings including swinging, sliding, jumping, launching, rocking, rolling, riding, twirling (Schaff & Smith Roley, 2006).

d.) Padlet link https://padlet.com/cwall10/vestibular-fun-dfrjxiya2d22p5lb

2. Stability/ Mobility interventions: The students will have opportunities for stability work on dynamic surfaces, which further activate the vestibular system, during 20-30 minutes of sedentary classroom time (such as read-a-loud) using a therapy ball, balance board, Hokki stool, or T-stool within the classroom setting. Dynamic surfaces will be available for multiple students within the classroom.

Resetting Engagement - Three Needs

Three types of brain breaks are needed to keep us sharp mentally, spiritually, and physically (Weslake & Christian): They include

movement / physical, respiratory, and mental brain breaks.

It’s just as easy to build this in as it is to forget. To build new habits, we need to first schedule them in and provide reminders, such a pictures or calendar reminders. Each of these brain breaks speaks to our vagal nerve for self regulation, impacting our health and affective domains toward our occupations.

Physical - the obvious - Get out and move. If possible, get outside. Repeatedly we hear of the benefits of nature, with a minimum of 20 minutes per day recommended to promote attention and well-being. Take a hike, walk the dog, climb the stairs, dance in your office or classroom or kitchen, or just get out and play.

Respiratory - Breathe. Five deep breaths scheduled throughout your day speak directly to your vagal nerve to positively impact your blood pressure and alertness. Connect deep breaths with something you do throughout your day to make it a consistent habit. Perhaps every time you eat / drink begin with five deep breaths - in through your nose and out through your mouth with the exhale taking twice as long as the inhale. Think of smelling the cake and blowing the candles or something pleasant with this association. Other respiratory breaks include humming, yawning, or singing. To activate a yawn, apply light pressure with two fingers on your TMJ (just in front of your ear on your jaw joint).

Mental - Periodically we find ourselves deep in concentration or working / learning for long hours and need to shift gears to allow our brains a chance to store information we have learned or experienced. Shifting occupations to a game or interactive / applied task or time away from the learning / work mode can allow our brain to process, store, and rejuvenate to maintain efficiency. Children need more frequent brain breaks to store knowledge. Encorage children to apply learning frequently within activity centered learning.

Mechanism of Change

Vestibular impact on complex motor sequences, learning, and spatial cognition

Vestibular sensations mediate cognitive performance through myelination and neural connections between main memory centers (hippocampus, amygdala, thalamus, frontal cortex, and cerebellum) and vestibulo-cortical tracts to develop processes for object recognition, body schema, inner speech, attention, impulse control, and a variety of mental activities including attributes of a theory of mind and executive function (Besnard, et al., 2018, Hitier et al., 2014; Kashfi et al., 2019; Lopez et al., 2020; Mast et al., 2014; Melo et al., 2019; Moossavi & Jafari, 2019; Schoen, et al., 2019; Watling & Hauer, 2015; Andelin, 2019; Lotfi et al., 2017; Matuszkiewicz & Gałkowski, 2021; Sadeghi et al., 2019) to support learning and communication in developing children who otherwise have failed to register adequate vestibular sensation.

In addition to promoting neural efficiency through myelination, patial cognition develops through vestibular modulation of information being processed in a specific spatial order, providing mental imagery, numeracy, navigation, and sequencing (Mast et al, 2014; Besnard, et al, 2016; Hitier et al., 2014). Posture, movement experiences, and perception, collectively referred to as “embodiment” (Lopez 2020), are supported by the vestibular system and provide a foundation through a sense of self (Besnard, et al., 2016; Lopez, et al., 2020) from which to navigate and engage with the environment and people and objects within it (Moossavi & Jafari 2019; Lopez, 2020). The capacity for sustained, self-directed engagement increases through the maturation of vestibular foundations and perceptual motor function, giving rise to focused attention, regulation, inhibition, and motor skill development (Kashfi et al., 2019; Mast et al., 2021; Lotfi et al., 2014; Lotfi et al., 2016).

Vestibular for Attention and Learning

Do you ever wondering why children who seem to be paying attention fall out of their chair or some children are always in motion?

Within the classroom setting, vestibular dysfunction is rapidly apparent in the student who repeatedly falls out of their chair when trying to pay attention. They are not receiving adequate vestibular signals to allow their automatic postural control systems to keep them seated. Instead, they must rely on focused attention to remain seated and have limited capacity left for engaging in learning.

For the child who is continuously in motion (self-seeking vestibular input) but never satisfies the need, a portion of their vestibular system is likely dysfunctional and not registering the sensation. Therefor, they would benefit from novel and intensive vestibular experiences to positively impact their developing system. Lived experiences show favoritisms toward lateral rotations as described by Kawar (2002; Kawar & Fricht, 2005) for a succinct and effective stronghold in promoting vestibular development in system that is under-responsive or under registering sensation.

Considering that children engage in a variety of vestibular operations throughout their school day (recess, transitions, brain breaks, travel, PE, etc), yet this system remains underdeveloped, indicates the necessity for interventions that offer novel and intensive actions to break into their system and elicit the desired response.

To effectively engage, a child’s postural control must be established, and vestibular, proprioceptive, and visual systems must be in sync (Kashfi et al., 2019). The capacity for sustained, self-directed engagement increases through the maturation of postural foundations and perceptual motor function, giving rise to focused attention, regulation, inhibition, and motor skill development (Kashfi et al., 2019; Mast et al., 2021; Lotfi et al., 2014; Lotfi et al., 2016). This mechanism of change is facilitated through prescribed vestibular interventions with children who present with generally neuro-typical characteristics and an under-responsive vestibular system manifesting in delays associated with motor development and learning (Hitier et al., 2014; Besnard, et al., 2018; Lotfi et al., 2017). 

Supporting Theories

Vestibulotherapy emerged through a combination of two supporting theories and years of lived experience in pediatric OT. The supporting theories include vestibular rehabilitation and Ayres Sensory Integration. So that you might fully understand the background, I will share the essential elements of these two theories.

Supporting Theory - Pediatric Vestibular Rehabilitation

Vestibular rehabilitation (VR) for children is designed to improve gaze stability, visual-spatial perception, balance, and motor development through exercises embedded throughout the child’s day. Pediatric VR activities employ repetitive and simultaneous head movements with visual focus, static and dynamic balance exercises, and challenging gross motor activities (Christy, 2019; Hall et al., 2016). Pediatric VR is intended for children with any degree of unilateral or bilateral vestibular hypofunction who also have difficulty with gaze stability, balance, and/or motor skill development (Christy, 2019).

VR evidence supporting the proposed mechanism of change is based upon three theories of neural plasticity: adaptation, substitution, and habituation (Hall et al., 2016). Adaptation invokes changes at the neuron level of the vestibular nuclei, impacting the remaining functional portions of the peripheral vestibular system (Christy, 2019). Substitution relies on compensation from other areas of the central nervous system (Christy, 2019). Habituation improves the individual’s tolerance to motion through desensitization through repeated motion over time (Christy, 2019).

Supporting Theory – Ayres Sensory Integration

Sensory integration is the process by which people register, modulate, and discriminate sensations received through the sensory systems to produce purposeful, adaptive behaviors in response to the environment (Ayres, 1972, as cited by Smith-Roley et al., 2007). In ASI there exists an intentional collaboration between child and therapist to create a play scheme, where the child actively engages in affordances of tactile, proprioceptive, and / or vestibular sensations, producing an adaptive response during occupations of play that employ the child’s strengths and challenges (Lane et al., 2019; Roley & Mailloux, 2020). It is through this adaptive response where sensory integration and neural connections develop in response to the child’s ability to receive and process sensation from movement and the environment and use it to plan and organize behavior (Lane et al., 2019; Roley & Mailloux, 2020; Smith-Roley et al., 2007). Without advanced training, ASI is often confused with other sensory based interventions, which provide tactile, vestibular, and /or proprioception to engage the child through means of regulation or modulation of sensory reactions. Unless its application meets the ten elements of fidelity (Parham, 2008, 2011), simply employing these sensory affordances is not Ayres Sensory Integration.

Ayres Sensory Integration (ASI) theory is based on the understanding that impaired sensory and neurological processing impedes development of skills needed for occupational performance. According to Dr. Ayres, children who demonstrate participation challenges often have vestibular-based deficits that could be readily improved through OT, resulting in greater performance in childhood occupations (Ayres 1978, as cited by Roley et al., 2007). Outcomes of Ayres Sensory Integration illustrate how sensory processing integrates with cortical systems to evoke change in our emotional, social, and learning pathways. Sensory Integration speaks to our abilities to receive and process sensory information from our environment, our stored perceptions, and from within our bodies so that we may learn and participate in daily social and academic occupations (Lane et al., 2019).

Through measures of fidelity, Ayres Sensory Integration has distinguished itself from other sensory-based interventions and become an area of evidence-based practice for children with autism (Shoen, et al., 2019; Schaff et al., 2015). While some of the most impressive gains included participation in self cares, increased independence with ADLs, and improved confidence, sense of self-worth, risk taking, and perceived social competence (Schaff et al., 2015), these were not the original aim of Ayres’ Sensory Integration theory (Aryes, 2005, 1976). Rather, Ayres’ focus was to improve academic performance for those children identified as having a learning disability (Aryes, 2005, 1976). “Learning is dependent on the ability to receive and process sensation from movement (vestibular) and the environment and use it to plan and organize behavior” (Roley, et al., 2007, p5). Through a combination of the ASI theory and contemporary neuroscience evidence of vestibular interventions for improving memory and cognitive processes, one could postulate a renewed connection for ASI to support learning outcomes (Lane et al., 2019; Hitier et al., 2014; Koziol et al., 2014; Besnard et al., 2018).

Through improved vestibular processing and sensory integration we develop ideation, body scheme, and internal maps that interact to connect knowledge about our body (sensory and motor maps) with thoughts and ideas to formulate new plans and envision increasingly more complex actions and interactions (Kaye, 2018; Lane et al., 2019). When we effectively take in sensory information and create sensory memories, we store these perceptual memories for later use to expand ideation. Similarly, we build perceptual maps, motor memory, and action schemas (motor planning to refined automated motor plans) to draw upon for increasingly more complex interactions with our environment (Mailloux & Roley, 2020). While building increasingly efficient sensory integration, one develops action chains, which are complex motor sequences that are linked together to provide efficiency with performing skills and navigating through more complex processes (Kaye, 2018). Developing pathways are reinforced by vestibular innervation, which increases memory, sequencing, and ordinance for language and motor skills (Kaye, 2018).

In consideration of this complex tiered learning through ASI, we begin to recognize how ASI, when done with fidelity, is so much more than sensory based interventions that are done to a child to help them regulate or modulate sensory input. ASI interventions including vestibular applications, improve body schema, perceptual awareness, repertoire of action skills, future actions, organizing time and materials, building increasingly complex motor schemes, and anticipating the need for action (Kaye, 2018; Mailloux & Roley, 2020). Outside of ASI, pediatric therapists need to advocate for clinical practice guidelines on developmental vestibular applications to meet the needs of children.

My Why - Vestibulotherapy

VestibulOTherapy is an emerging frame of reference, grounded in contemporary neuroscience evidence with supporting theories from OT-Ayres Sensory Integration and vestibular rehabilitation. Through its application, children with vestibular under-registration will experience adequate vestibular activation to generate myelination and develop neuropathways supporting communication and learning.

Through a combination of etiologies, the suspected prevalence of pediatric vestibular dysfunction impacts approximately 3.3 million US children annually, while few receive appropriate diagnosis or treatment (Li et al., 2016). For comparison, the most recent statistics indicate a prevalence rate of 2.3% frequency of autism in US children (Maenner et al., 2021). Delayed maturation of this vital system may be related to increasingly sedentary and low-risk lifestyles or compromise from inner ear functioning. With increasingly sedentary landscapes, evidence-based practice and supporting literature is needed to inform and guide OT practitioners in the identification and application of vestibulotherapies to support children struggling with communication and academic performance. Vestibulotherapy principles will guide therapists in the identification and intervention of delayed vestibular maturation through a combination of clinical and home or classroom-based activities that are embedded into the child’s occupations of play and learning.

Movement anchors learning - but how?

Did you ever wonder why kids, who seemingly want to pay attention, fall out of their chair while working in the classroom? Or why some children are always moving and cannot stay still? Their underperforming vestibular system is either not providing adequate feedback to maintain posture or sending them signals to activate the system through movement. How does this idea fit with the common notion that “movement anchors learning”?

Through decades of working with children, it has become increasingly evident that the vestibular system is the foundation on which learning becomes possible. Through its connections to the visual and auditory systems, as well as the thrust for myelination leading to the frontal cortex, the vestibular system drives learning and memory, while supporting our attention and engagement.

The basis for this research emerged from my observations of children’s learning in response to vestibular interventions. As children become increasingly more sedentary in a low-risk landscape, it is more important than ever for occupational therapists in school based or pediatric OT to provide quality, evidence-based treatment focused on improving vestibular maturation to support learning and communication.

A high prevalence of children’s vestibular dysfunction remains undetected and untreated (Li et al, 2016), manifesting challenges relating to learning and communication. A historical dearth of knowledge and evidence supporting children’s vestibular maturation has been the inspiration for creating vestibulotherapy.org. Through evidence from contemporary neuroscience and 20+ years of clinical observations, vestibulotherapy.org will provide meaningful resources and learning opportunities for parents, teachers, therapists, and medical professionals to increase awareness and intervention of children’s delayed vestibular maturation, supporting positive outcomes in roles of learning and communication.