When most parents think of sensory processing issues, they think of the children who hate clothing tags and gag on textured foods. Joint hypermobility, regardless of the reason (prematurity, Ehlers-Danlos syndrome, head injury, etc) can result in kids who stumble when they move and wobble when they rest. They are seen by orthopedists and physical therapists, and told to build up those weak muscles. Well, hypermobile kids have sensory processing issues too! And they deserve more effective treatment for these issues than they typically receive.
Lack of joint integrity, especially decreased joint stability, results in a decrease in proprioception and kinesthesia. These two under-appreciated senses tell a child about her body’s positions and movements without the use of vision. The literature out there is sparse. If you are hoping that a lot of research on this topic exists, and that your pediatrician understands why your child can’t grasp a pencil but can squeeze the @@#$% out of Play-Doh, good luck. Who will understand you? Your OT.
Most of the hard research into proprioception and hypermobility has been done by PTs and focused on proprioception in the leg. They are interested in how it affects mobility. The problems with poor proprioception and kinesthesia go far beyond walking. Essentially no research has been done on hand function or the practical application of research to living skills of any kind when it comes to hypermobility syndromes and proprioception. But OTs can teach you and your child’s classroom staff about the connections between sensory processing and motor performance. They can help your child improve skills based on their knowledge of neurology and function.
Here is a simple explanation of how proprioception and kinesthesia affect function. Consider the process for touch-typing. Your awareness of your hand’s position while at rest on the home row is proprioception. You know where your movement starting and end points are via proprioception without looking. Your awareness of the degree of movement in a joint while you are actively typing is kinesthesia. Kinesthesia tells you that you just typed a “w” instead of an “e” without having to look at the screen or at your fingers.Your brain “knows”, through learned feedback loops, that your finger movement was too far to the left to type the letter “w”, but far enough to have been a “e”. Teachers and others call this “muscle memory”, but that is a misnomer. Muscles have no memory; brains do. And brains that aren’t getting the right information send out the wrong instructions to muscles. Oops!
You are able to grade the amount of force on each key because your skin, joint and muscle sensors transmit information about the resistance you meet while pressing down each key. Your brain compares it previous typing success and the results on the screen, and makes adjustments in fractions of a second. This is sensory processing at work.
Why do children with hypermobility have proprioceptive and kinesthetic processing problems? Because information from your body is transmitted is through receptors embedded in the tissue within and surrounding the joints. These receptors respond to muscle and tendon stretch, muscle contraction, and pressure within the joint. Joint hypermobility creates less stimulation (and thus less accurate information) to these sensory receptors. Like the game at the carnival, the ball isn’t hit hard enough to ring the bell at the top of the post. The sensory information coming into the brain is either insufficient or delayed (or both), and therefore the brain’s output of directions to achieve postural stability or dynamic movement is correspondingly poor.
This shows up as a collapsed posture, difficulty quickly changing positions to catch a ball or leap over an obstacle, a heavy-footed gait, and a whole lot of other difficulties. Has your child been described as fidgety or distracted? Read Hypermobility and ADHD? Take Stability, Proprioception, Pain and Fatigue Into Account Before Labeling Behavior. Hypermobility can even make speech and feeding more challenging. Read Can Hypermobility Cause Speech Problems? to learn more about the signs that your child may benefit from speech therapy as well as OT and PT. Does your child struggle with pencil grasp? An atypical grasp can actually be helpful, but you need to know which patterns are harmful and which support performance. Please read Does An Atypical Pencil Grasp Damage Joints or Support Function In Kids With Hypermobility? , and For Kids With Sensory Issues and Low Tone, Add Resistance Instead of Hand-Over-Hand Assistance for more information that you can share with your child and teachers as well.
Because many hypermobile children are able to accomplish the basic developmental milestones within a reasonable time period, pediatricians don’t pick up on mild hypermobility until kindergarten. This is when sitting at a table for longer periods becomes the expected norm, and holding a pencil in a mature way is required. To learn more about why your child’s grasp is an issue, take a look at The Hypermobile Hand: More Than A Strength Problem.
Can children with hypermobility improve their sensory processing and thereby improve the quality of their movements in daily life? Absolutely. Because sensory processing is a complex skill, addressing each component of functional performance will give the hypermobile child more skills. Building muscular strength within a safe range of joint movement is only one aspect of treatment. If your child is experiencing difficulty in gym or playing sports, please read Should Your Hypermobile Child Play Sports? for some useful ways to think about what you say to your child. Positioning a child to give them more sensory feedback while in action is essential. Increasing overall sensory processing by using other sensory input modalities is often ignored but very helpful. To learn more about how to help your child handle hypermobility, check out Is Your Hypermobile Child Frequently In An Awkward Position? No, She Really DOESN’T Feel Any Pain From Sitting That Way and Hypermobile Kids, Sleep, And The Hidden Problem With Blankets.
I’ll bet that you didn’t think of toileting as a proprioceptive issue. When thinking about toileting the hypermobile child, the biggest problem is often an interoceptive issue; the kind of proprioception that involves internal organs. This can make it difficult for hypermobile kids to feel when they need to “go” in time to get to the bathroom, but it can also create retention. The urge isn’t very powerful for them. Read For Kids Who Don’t Know They Need to “Go”? Tell Them to Stand Up and Teach Kids With EDS Or Low Tone: Don’t Hold It In!. And of course, you might want a book that will help you with training. I wrote it: The Practical Guide to Toilet Training Your Child With Low Muscle Tone: Potty Training Help Has Arrived!
I believe that vestibular input is one of the most powerful but rarely used modalities that can improve the sensory-motor performance of hypermobile children. They don’t have to demonstrate vestibular processing deficits to benefit from a vestibular program. The lack of effective sensory processing due to poor proprioceptive registration and discrimination creates problems with balance, and targeted vestibular input is designed to fine-tune the brain’s balance center. I could link you to scholarly articles on this concept, but you would fall asleep before finishing them. Trust me, vestibular input can make a difference. This program can be done without stressing fragile joints, which is often a limitation for the programs that focus too much on muscular strengthening and stabilization activities.
My favorite sensory processing strategy for hypermobile kids? The use of rhythmic music during movement. Therapeutic music programs that use the powerful effects of sound on the brain are effective treatments for hypermobile children. Using sound to improve vestibular processing increases the quality and the speed of response to a loss of balance. Muscle tone increases in children while they are listening through stimulation of midbrain centers, and this combo of improved tone and improved vestibular processing helps children improve their safety while moving and even while sitting still. For all of you with kids who fall off chairs while doing nothing, you know what I mean! I have been trained in the use of Therapeutic Listening through Vital Sounds, but there are other programs that work well too. The most significant benefit is that there is no stress on connective tissue, even for kids that are in a lot of pain and have very limited mobility. For kids that have POTS as well as hypermobility, this can be a real advantage. Treatment of the vestibular system can improve the ability of the autonomic nervous system.
Another technique to enhance sensory processing is the Wilbarger Protocol. Although not created for children with hypermobility, I believe that it can be altered to address poor proprioceptive discrimination in specific conditions such as EDS. Read Can You Use The Wilbarger Protocol With Kids That Have Ehlers-Danlos Syndrome? for a look at how I adapt the protocol with safety in mind.
Kineseotape can be helpful to provide some of the missing proprioceptive information. When your child has a connective tissue disorder, or is under the age of 3, skin issues complicate taping. Read Can You K-Tape Kids With Ehlers-Danlos and Other Connective Tissue Disorders? for some suggestions to make this treatment more effective and less risky.
It is difficult to explain to insurers and sometimes even neurologists ( don’t get me started on how hard it is for orthopedists to follow this), but if you understand the complex processes that support sensory processing, you will be changing the background music in your clinic or your home in order to capitalize on this effect! I recommend the Vital Links Therapeutic Listening programs for their ease of use and child-friendly music.
Children with hypermobility can benefit from occupational therapy sessions that provide more than a pencil grip and a seat cushion. All it takes is an appreciation for the sensory effects of hypermobility on function.
Does your hypermobile child also have toileting issues? My e-book, The Practical Guide To Toilet Training Your Child With Low Muscle Tone, could help you make progress today! Many children with hypermobility also have low tone, and the theories and strategies that support stability and sensory processing are totally applicable for hypermobile kids! This book has readiness checklists and strategies that parents can use to make real improvements in skills, not platitudes like ” read your child’s signals” and “don’t push your child to train”. You will learn about the sensory, motor, and social/emotional issues that contribute to toileting delays, how to select the right equipment, clothing, and more!
The Practical Guide is available on my website, tranquil babies and on Amazon as well as at your therapy source, a great place for therapists and parents to find exercise programs and activities for children. Read more about it, and hear what parents have to say about this unique e-book:The Practical Guide to Toilet Training Your Child With Low Muscle Tone: Potty Training Help Has Arrived!