선천적이든 후천적이든 많은 임상적인 장애들은 집중력, 운동 계획, 협응 기능, 정신 조직화, 순차적 처리 기능에 문제가 있는데, 미국 정신의학회 정신 장애 통계 편람(DSM-Ⅳ)에서 보면 ADHD, 정신지체, 전반적 발달 장애, 발달성 협응 장애, 학습 장애, 인지 기능 장애들이 이들 기능의 이상을 포함하고 있다.
IM 훈련의 목표가 ‘타이밍’, 리듬(rhythmicity), 집중력, 운동 계획 등에 있어서 인지 기능의 향상이 두뇌의 신경가소성(neuronal plasticity: 훈련에 의해서 신경학적으로 훈련의 효과가 장기적으로 입력되는 현상)에 어떻게 영향을 주는지가 최근의 초점이 되고 있다.(shaffer et al, 2001: Libkuman, Orani Steger, 2002)


IM의 주요 연구 분야

fMRI Scan of Adult Brain from Dr. Alpiner’s Study


1. 신경학적 가소성 (Neuronal Plasticity)
: 훈련에 의해서 훈련에 의한 신경학적 변화가 지속되는지에 대한 연구.

2. 싱크로나이즈와 타이밍 (Synchronization and Timing)
: 여러 가지 동작을 동일한 시간에 일치시키는 능력을 말하며 이러한 운동 훈련을 통해서 신경학적 협응 능력과 인지 기능의 시간적인 일치 능력이 향상될 수 있다. 순차적 운동 기능은 특히 전두엽(frontal lobe)과 두정엽(parietal lobe)이 주로 포함되고 있다. 그리고 싱크로나이즈 기능에 대한 연구에서 대상회 운동 피질(cingulate motor cortex), 일차 감각 운동 피질(primary sensorimotor cortex), premotor cortex, supplementary motor cortex, 소뇌(cerebellum) 에서 관장하는 것으로 연구되고 있다.

3. 운동 계획 (Motor Planning)
: 운동계획에는 집중력(attention), 감각 통합(sensory integration)과 싱크로나이즈(synchronization), 타이밍(timing)의 협동이 필요로 되어진다. 예를 들어 물컵에 있는 물을 마시기 위해서는 물잔을 눈으로 지각해야 하고, 자기 고유 수용성 감각(proprioceptive sense) 기관에서 물컵이 어디에 있는지를 파악하고 특수한 근육의 활동을 활성화시키기 위한 특수한 운동 동작이 필요로 되어진다. 점진적인 시간적으로 순차적인 운동 습득 능력이 있어야 정확한 수행력에 필요하다. 각기 다른 감각을 통합하고 싱크로나이즈 (동시에 여러 동작을 일치시킴)하는 능력은 두뇌의 각기 다른 부위가 통합되어서 작용하는데 특히 premotor area, 전전두엽(prefrontal lobe)이 이러한 기능에 관여한다. 이러한 감각 운동 일치 능력은 IM 훈련의 주요 목표가 된다.

4. 리듬 기능 (Rhythmicity)
: 각기 다른 감각 모드로부터의 정보를 각기 다른 두뇌 피질에서 처리 되어진다.
두뇌의 후반 두정엽과 전두엽이 감각 협응에 있어서 다양한 모드의 공간적 재현 기능에 관여하고 있다. 반복적인 운동과 리듬성의 청각적 자극을 동시에 일치(synchronization)시키기 위해서는 실수에 대한 교정(error correction) 기능이 요구되어진다. 감각 운동 일치 혹은 리듬 기능 템포 변화에 종속되는데 이러한 템포 변화는 두 가지 내적인 정보 처리 과정 즉 단계 교정(phase correction)과 기간 교정(period correction)이 관여한다.
단계 교정(phase correction)은 각기 다른 감각 모드의 자극 사이의 내적인 동시성 실수(internal synchronization error) 혹은 비동시성(asynchronous)에 근거되어 진다. 이러한 단계 교정은 주로 자동적이며 내적인 타임 키퍼(time keeper)에 의해서 생성되는 자극 지각 사이에 시간적 간격에 적응하는 훈련을 통해서 교정된다.

2001년 RePP에 따르면 단계 교정은 자극이 시간적으로 균등한 간격으로 주어질 때 동시성을 유지시키는 능력이 개선되어진다. 기간 교정(period correction) 의식적인 자각과 집중을 요구하는데, 운동 활동의 페이스를 조절하는 타임키퍼(timekeeper)의 시간적 간격을 수정해 준다. 단계와 기간 교정의 연구에서 템포 변화를 포함하는 순차적 청각적 자극과 손가락 두드리는 과제를 동시에 일치시키는 연구가 있어왔다. 단계 교정이 주로 의식적인 의도(intention)에 주로 의존하는 반면 기간 교정은 주의가 흐트러지는 것(distraction), 의식적 자각과 지시와 관계가 되어졌다.
그러므로 집중과 의식적 자각은 지시된 행동을 하는데 통합적인 역할을 한다. 다른 감각 통합 연구에서, 청각적인 자극이 시각적 자극보다 더 지배적이라고 밝혀졌다. (Aschersleben & Bertleson, 2003; Hickok Buchsloaum, Humphries & Muftuler, 2003; RePP, 2003)

IM 훈련을 수행하는 동안 충분한 집중력뿐 만이 아니라 청각과 자극을 융합하는 기능이 강화된다; 다중 감각 모드를 자극하고 리듬 기능을 유지하기 위해서는 기간 교정(period correction)이 요구되어진다.

5. 집중기능 (Attention)
집중은 자극에 대한 선택적 초점 맞추기, 집중을 유지, 공간과 시간의 상호 작용 등이 관여된다. 집중은 통합적 인지 기능이며, 감각, 운동, 인지 기능을 강화시킨다. 그리고 개인의 집중 능력에 주요한 부분이 각성 수준(arousal level)이다.
그러나 각성 수준이 좋다고 반드시 집중력이 좋은 것은 아니다. 그러므로 집중력은 다양한 차원의 구성 요소를 가지고 있다. 선택적인 집중력은 환경에서 일어나는 자극에 집중하고 주변 자극을 무시하는 능력이다. 반면, 분산된 집중력(Divided Attention)은 여러 자극을 동시에 자각할 수 있는 능력이다.
경계심(vigilance)는 특수한 자극에 집중을 하면서도 예측할 수 없는 자극을 탐지하는 기능이다. 집중력에 대한 이론을 해부학과 행동학적 모델이 있다. 해부학적 모델은 “top-down" 모델로써 자극 형태에 대한 집중력의 상호 작용이 아니라 집중과 공간적 측면에 관계되는 피질 영역이 포함된다. "Bottem-up" 모델은 이들 자극에 의해 활성화되는 피질 영역에 의해 조절되는 자극 사이의 경계 개념이 포함된다. 집중력은 두 모델 사이의 상호작용으로써 정의된다.

IM 훈련 임상 연구들의 결과를 요약하면,
양측성 협응 능력과 균형 기능이 개선됨.
감각 정보 처리 기능, 행동적이고 정서적인 반응, 시간적인 견디는 능력, 신체 포지션과 움직임, 주의산만/주의가 흐트러지는 것이 개선됨.
과제하기가 개선되고 아이디어가 풍부해짐.
개념과 논리성 뿐만 아니라 글쓰기가 개선됨.
6개월 넘게 집중력의 개선이 지속됨.
타이밍과 리듬 기능 정확성이 개선됨
감각 정보처리 기능과 운동 계획, 순차적 처리 기능, 협응력, 조절 기능, 균형 기능이 개선됨.
집중력과 집중 유지, 초점 맞추기 능력이 개선됨.
언어처리 기능을 포함하는 인지 능력과 판단하고 결정하는 기능이 개선됨.
읽고 이해하기, 읽기, 수학, 음성학적 기술, 글쓰기를 포함하는 학업 수행 능력이 향상됨.
충동성과 공격성이 줄어듬.
다른 행동 조절에도 관여됨.




각 영역에서의 IM 임상 연구

작업 치료 Occupational Therapy

수년 동안, 작업 치료사들은 일상 생활에서 독립적인 활동을 하도록 매일 도와주어야 하는 환자들에 있어서 운동 계획과 순차적 처리 기능이 굉장히 중요한 역할을 한다는 것을 깨닫게 되었다. IM 훈련에 대한 임상 연구에서도 리듬과 타이밍 능력이 개선됨으로써 다음과 같은 여러 영역에서 수행 능력이 유의한 수준으로 회복된다는 것이 입증되었다.

운동기능
균형
양측성 협응 능력
감각 통합


운동계획과 순차적 처리 능력

American Journal of Occupational Therapy에 개제된 IM에 대한 연구(entitled “Theoretical and Clinical Perspectives on the Interactive Metronome ? A View from Clinical Occupational Therapy Practice”)에서 공간과 시간에 대한 싱크로나이즈 즉, 여러 동작을 동일한 시간에 일치시키는 감각통합 기능에 장애가 있는 사람들이 세상과 신체/사회적인 상호 작용뿐만 아니라 수면을 조절하는데 필수적인 타이밍(Timing)의 내적 감각이 부족하다는 것이 증명되었다. 덧붙여, 시간과 공간에 대한 큐(“cue”)에 정확한 지각이 반드시 필요한 시공간 조합 능력에 어려움이 있는 것으로 보고되었다.

IM 훈련이 감각 통합 기능을 현저하게 개선시킬 수 있다는 연구가 보고되었다.


“집중, 학습 능력 그리고 문제 해결 능력은 행동과 생각을 계획하고 순차적으로 처리하는 능력에 달려 있다. IM은 개개인에게 체계적으로 운동을 하도록 도와주고 기본적인 운동 계획과 순차적 처리 능력을 향상시킨다”

- 저명한 소아 정신과 의사이자 IM의 과학 자문 그룹의 회장이며,
미국 정신 보건 연구원(NIMH)의 전임 연구원장 Stanley Greenspan


“작업 치료사들은 IM이 소아와 성인의 리듬, 타이밍/순차적 처리 기능을 개선시킬 수 있는 훌륭한 훈련 도구이며, IM 훈련을 통해 협응력, 초점 맞추기, 정보 처리 능력이 현저히 개선되었다고 주장한다.”

- Jane Koomar, Ph.D., OTR/L, FAOTA Executive Director,
Occupational Therapy Associates in Watertown, MA


“플로리다의 HealthSouth Sunrise 재활 병원에서 우리는 입원 또는 외래 성인/소아 환자를 대상으로 기존의 여러 전문적인 치료와 함께 IM을 시행하였다. IM 훈련은 입원치료 프로그램에서 외래 치료 프로그램으로의 환자들의 변화 추이를 촉진시켰다. 여기서 집중력이나 정신적 과정 뿐 아니라 걸음걸이와 통합에서의 의미 있는 개선을 가져왔다.”

- Cheryl Miller-Scott, OTR/L,
National Director of Clinical Services, HealthSouth Hospitals


언어 치료 Speech Therapy



많은 언어학자들은 언어 표현의 병리적 원인으로 말하기, 언어, 의사 소통 기술, 인지 능력의 습득에 운동 계획/순차적 처리 기능이 중요한 역할을 한다는 것을 인식했다.
IM은 이와 같은 기능을 개선시킬 수 있는 방법 중 하나이다. IM 훈련을 통해 언어 구사와 인지 기술을 발달시킬 수 있다.
신경 가소성(Neuronal Plasticity)을 통하여 IM의 신경 운동 훈련은 손상 혹은 발달 지연을 보상할 수 있는 새로운 신경 회로를 만들거나 적응할 수 이도록 뇌를 자극한다.
IM 훈련은 다음과 같은 영역에 도움이 된다.

언어 프로세싱
사회적 의사소통
계획성과 순차적 처리 기능
집중력
충동성과 공격성 조절

“IM 훈련은 집중, 운동 협응 뿐만 아니라 언어 운동과 순차적 기능 측면에서도 매우 도움이 된다는 것을 경험했다. 나는 언어 병리 치료사들에게 어린이들의 의사 소통 장애 훈련을 꼭 권장하고 싶다.”
- Lorrainne Jones, Ph.D., CCC SLP, Director,
Kid Pro Therapy Services and author of ‘The Source for Expressive Language Delay’


“지금까지 사용했던 다른 방법들과 같이 나는 IM을 높이 평가한다. 나는 IM이 두뇌에 변화를 주어 짧은 기간 안에 효과를 볼 수 있다고 믿는다.”

- Aditi Silverstein, M.A., CCC SLP,
President of Center for Rehabilitation and Development, Inc. in Roanoke, VA


물리 치료 Physical Therapy


물리 치료사들은 IM을 환자의 운동 계획과 순차적 처리 기능을 평가하고 개선시키기 위해서 IM을 사용한다. 인터액티브한 훈련 과정에서 환자는 반복적으로 손 운동, 발 운동, 발꿈치 운동, 체중 이동, 좌우양측 운동 협응 동작을 하게 된다.
이러한 운동 과정은 고도의 집중력을 요하고 훈련 또한 다른 신체 운동에서 경험할 수 없는 참을성을 요구한다. IM 훈련은 손발이 절단된 환자, 발달성 협응 장애 균형 문제와 관계되는 질환 등에서 운동 조절 능력을 짧은 시간내에 획득하게 한다.

IM은 신경학적/운동 재활 훈련 프로그램으로 다음과 같은 곳에 도움이 된다.

신체적 인내성
일치된 걸음걸이
협응 기능
운동 기술
균형


“나는 IM 훈련이 좌우 양측 통합 기술, 순차적 처리 능력 타이밍, 한쪽 발로 몸을 오래 유지하기, 참을성 훈련 등에 매우 효과적이라는 것을 발견했다.”

- Tracy Cueil-Dutil, D.P.T.,
Miami Children’s Hospital/Dan Marino Center Miami, FL


“IM 훈련은 무릎이나 다리 절단 환자의 재활 훈련에 상당히 효과가 있었다. IM 훈련을 통해 상당한 수준의 미세 운동 기술도 회복이 되었다.”

- Patty Bohr, PTA,
HealthSouth Sea Pines Rehabilitation Hospital in Melbourne, FL



Interactive Metronome 현재 사용 기관

현재 전문가 교육을 받은 therapist는 미국 내 3,000여명 이상
: 계속 증가되고 있음. 매주 한번씩 교육이 있음.
미국 내 1,700개 병원, 클리닉, 대학에서 사용



IM 연구 고문 위원회 구성

Clinical Professor, Chief of Pediatric Psychiatry, George Washington Medical School
Stanley I. Greenspan, MD, Chairman
Former Director of NIMH
Tightly controlled clinical research began



미국내 주요 대학에서의 IM 임상연구

Creighton University Medical Center
Medical College of Georgia (MCG Health)
Rusk Institute (NYU)
University of North Carolina
University of Notre Dame
Duke University
Louisiana State University
University of Kansas Medical Center
University of Rochester
East Carolina University
Arizona State University
University of Washington
The University of Utah
College of Staten Island
Cerritos College
Nova Southeastern University
Youngstown State University
Widener University
Marquette University
Boston University
Grand Valley State University
University on Nevada
University of Miami
Johns Hopkins University
MCP - Hahnemann University
Texas Womens University
California State University
Rider University

Initial Evaluation
Michael came to the provider’s office, which is located in an outpatient facility that provides physical therapy, occupational therapy, and speech therapy for children. Because of his diagnosis of Autistic Disorder, it was decided that IM should be performed in a secluded room with only the provider and the patient present to reduce distractions.

Michael was initially very interested in Interactive Metronome and quickly understood the concept of “hitting” the reference tone. The IM pretest Long Form Assessment was administered. Michael was able to follow directions fairly well but had some difficulty maintaining attention to task. He especially had difficulty with the lower extremity movement patterns and required repeated verbal and physical cues to stay on task. The results of the assessment are shown below:

Development of an IM Plan for Michael
The provider had some concerns when developing an individual plan to suit Michael. First, because he was so young at the beginning the IM treatment, it was decided, after discussions with both parents, to begin with only half-hour sessions, three times per week. All IM treatment was to be performed in a room with little distraction and no other people in the room. Because Michael was so easily distracted by outside activity, even having his parents observing would have made it impossible for him to maintain his attention in the session. The second concern was his small size, which created difficulty in hitting the foot trigger with enough force to record a hit without moving in a ballistic or non-rhythmical movement.

Modifications Made for Michael
Michael began performing IM with only half-hour sessions due to his poor ability to maintain attention to task. The first four sessions involved only upper extremity activities since he had such great difficulty hitting the foot trigger. The provider gradually taught Michael the proper movements and began introducing the guide sounds slowly. He quickly grasped the concept of hitting “right on” the reference tone, and within five sessions, the provider was able to increase the length of IM treatment sessions to one full hour. At about the same time, Michael no longer required any hand-over-hand assistance and was able to imitate the proper hand movement with only visual or verbal cuing.

Michael’s attention to IM tasks continued to improve; however, he would become fatigued quickly, so for the next four or five sessions a total of 10 minutes (500 repetitions) or less was required from him with rest periods after each task. Because of some sensory integrative issues, Michael found the headphones irritating after a short period. The provider began giving him a two-minute break that allowed him to become more organized and ready to complete the next tasks. Often the provider would have him stretch or do a somersault before resuming with the next tasks. In addition, he was seated in an appropriate chair with no armrests for parts of the session in order to reduce fatigue and allow him to complete longer duration tasks.

Performing lower extremity tasks was still difficult for him due to his small size. The provider asked the parents to ensure that Michael was wearing the appropriate shoes, and by sessions eight and nine, he began tapping toes in a seated position. This worked quite well for him, and he was able to perform those lower extremity exercises with increasing “rythmicity” and less ballistic movement. His scores began to improve. Other lower extremity exercises such as “balance left foot /tap right toe” were performed with him holding onto a desk or chair. He continued to have significant difficulty with heel exercises.

Interim Testing and Parent Involvement
By session eight, the provider met with both parents. Everyone involved concurred that Michael should not yet be administered the IM interim Long Form Assessment. He was still having difficulty with most of the lower extremity exercises. His attention to task and his gross motor skills were steadily improving. It was decide by all to continue with one-hour sessions modified as described above and to continue past the 15 sessions originally planned as long as he continued to make steady progress. Michael’s parents were reporting improvement in attention to tasks at school and in gross motor skills during play activities.

The Next Phase
In the following sessions, the provider began to increase the durations of the tasks, up to almost 28 minutes (1,500 repetitions) per task by the eleventh session. Most sessions were focused on upper extremity tasks and included just a few short duration lower extremity tasks involving exercises such as toe tapping or balance on one foot. Michael began achieving “bursts” of four Super-Right-On (SRO) trigger hits in a row during his upper extremity tasks and was given a positive “reinforcer” such as a sticker for each burst. This proved to work very well with him. The number of bursts continued to increase steadily as his ms average continued to decrease (on upper extremity tasks).

Completing Michael’s IM Program
Michael continued to make progress and performed a total of 23 sessions. Toward the end of the sessions, he began to plateau in his progress, and his behavior occasionally became an issue. The IM posttest Long Form Assessment was performed, results shown below:

Other Improvements
Following IM treatment, his physical therapist reported an improvement in Single Limb Stance time from two to four seconds. In addition, he was able to perform jumping jacks with only a visual cue. Both his balance and gross coordination were markedly improved. He began hopping with either foot for three consecutive hops without loss of balance. Michael’s parents and teachers reported an improvement in his ability to stay on and complete a task as well as an improvement in his ability to focus.

Conclusion
Michael’s progress with IM shows the ability of children with challenging diagnoses to benefit from IM treatment. It also demonstrates that with modifications for individual needs, progress can be significant.


CAPD & Add

“Pam”, a ten-year-old girl diagnosed with Central Auditory Processing Disorder (CAPD) and Attention Deficit Disorder (ADD) struggled at home and in the classroom. Her parents noticed that she threw temper tantrums when she shifted from one task to another as well as when she was given a challenging task. In the classroom and in her homework, she showed language related difficulties in reading and math tasks. Pam had received Wilson Reading Instruction with the reading specialist at her school during the previous year. Decoding and comprehension skills were noted as her primary deficit areas.

Her parents brought her for Interactive Metronome (IM) treatment during her summer break. Initially, Pam was uncommunicative during her IM sessions and was unconvinced of the value of yet another remedial program interfering with her summer.

First, Pam was given the Gray Oral Reading Inventory-4 (GORT-4), to assess her reading rate, accuracy, fluency, and comprehension. The test showed she fell below average in all areas.

An IM pretest assessment was also administered revealing that Pam had significant motor planning and sequencing difficulties. This confirmed the other test results as well as the therapist’s observations.

Pam proved inattentive even during the short task durations required in the assessment, and her vigilance appeared weak. Although she appeared to understand the task directions and reported as such, she often ceased following them during the tasks. This was especially evident in the IM Attend-Over-Time Test.

A treatment plan was developed to meet Pam’s individual needs based on the observations of her behaviors during the IM assessment, notes of conversations with her parents, and her test results. To allow Pam to feel more in control of her treatment plan, sessions were scheduled with her interests in mind. The mid-morning, three times per week appointments allowed her to sleep-in and to still be available to play with her friends.

Trying to motivate her to participate in a treatment that took time away from her summer vacation days was the first challenge presented. A simple reward system was devised where Pam earned a small token prize from a treasure box at the end of each session if she reached her goal. The goal changed depending upon the activities planned for the session. Pam’s highly competitive nature made her eager to beat her own scores and performance levels. She entered the second session confident that it would be easy to better her previous scores but still moved haphazardly near the end of a long IM exercise. When she checked the results, she was surprised not to have improved as much as she expected, and then became determined to put forth more effort. Her efforts in IM improved as the weeks progressed, with Pam entering each session in a positive frame of mind by the last five sessions.

After meeting the objectives set forth at the beginning of her IM treatment program, Pam completed the IM posttest assessment. Her performance on the posttest demonstrated a 72% improvement over the pretest. She also showed an 87% improvement in her ability to attend to a task.

Pam’s family reported a decline in temper tantrums as she progressed through IM treatment with no occurrences in the last week of the treatment. She became more pleasant in her social interactions both in the clinic and with peers at the community pool. Pam also asked to receive tutoring in math and wished to continue IM through the fall season. This was a significant change in character for Pam since she previously viewed her remedial sessions as a chore. Additionally, her scores on the posttest GORT-4 were dramatically improved in comparison to her pretest results: reading rate ? 75th percentile (16th at pretest), accuracy ? 84th percentile (50th at pretest), fluency - 84th percentile 37th at pretest), and comprehension ? 91st percentile (25th at pretest).

The effects of Interactive Metronome treatment on reading fluency and comprehension are demonstrated by Pam’s gains. The positive outcomes noted in her attention, behavior, and in the reading related areas can be attributed to Interactive Metronome since no other interventions were conducted concurrently for the duration of the IM treatment.

For more information visit www.interactivemetronome.com

Barbara Fuoco-McCooley, MA CCC-SLP, is a certified Interactive Metronome provider and the Director of Innovative Designs for Educational Achievement, LLC in Moorestown, New Jersey. Their web site is www.innovative-educational-solutions.com





IM HELPS CHILDREN WITH CEREBRAL PALSY

The Interactive Metronome (IM) has been shown to help conditions in children diagnosed with Cerebral Palsy. This advanced brain-based treatment program was developed to improve the processing abilities that affect attention, motor planning and sequencing. This, in turn, strengthens motor skills, including fine and gross motor function, mobility, and many fundamental cognitive capacities such as: planning, organizing, and language.

Therapists and physicians understand the correlation between the neurological functions of motor planning and sequencing and the critical aspects of human development, such as: basic thinking, organizing, language processing, reading fluency, comprehension, phonological awareness, and coordination. When a child or adult demonstrates a deficit in motor planning and sequencing, it is typically accompanied by problems in learning, coordination, or behavioral control.

Prior to the development of Interactive Metronome, Inc. (IM), therapists were able to identify patients with these difficulties, but there was no system for measurable assessment and improvement. Today, we know how to measure a child's motor planning and sequencing abilities and we can show functional improvements in a short period of time.

Over the course of the treatment, patients learn to:

Focus and attend for longer periods of time
Increase physical endurance and stamina
Filter out internal and external distractions
Control fine and gross motor skills
Improve their ability to monitor mental and physical actions as they are occurring

CASE STUDY
Valeri is a 12 year old who came to Focus Point Therapy specifically for Interactive Metronome treatment. Her personal goal was to wear a pair of blue jeans like all of the other children in her regular classroom. She couldn't manage the zipper or the snap due to poor bilateral hand strength and lack of control from Cerebral Palsy. She had an imbalance of tone between the right and left side of her body. She was very quiet and rarely spoke at home or in school. She was very sedentary, spending most of her time in her room. In addition, she didn't have friends; but, she had a very active younger brother. She needed help with self-care and hair maintenance. When she drank liquids, she lacked tongue control and often aspirated part of the liquid as she swallowed with large gulps. When the therapist was testing her on the IM pre-test she went from standing to nearly falling over because she lacked stationary standing balance and she possessed a very awkward gait.

In just 3 sessions Valeri was able to go from assisted IM exercises to doing them on her own. Using creative clinical techniques, she did hundreds of repetitions of the reciprocal foot movement on the sensor pad, sometimes missing the pad; but, continuing with determination. I received a call from her mother who stated that Valeri, for the first time, went to the refrigerator to pour herself a glass of juice without anyone assisting. She started to talk, not just a little, but all the time. At the first teacher conference, the teacher remarked that Valeri was participating and raising her hand to give answers. Her grades dramatically improved from her usual C level work up to A and B+ levels. In therapy when she needed a break, she would get on the suspended bolster swing and talk non-stop about planets and the solar system - her favorite interest. The next thing I noticed was her ability to swallow improved. She had better tongue control and she didn't aspirate, as had previously been the case. Her personality kept flourishing and she was full of never before revealed information. Her confidence was very evident and she…was wearing her first pair of blue jeans like all the rest of the kids, managing them independently.

Interactive Metronome, Inc. Toll Free 877-994-6776 or visit www.interactivemetronome.com

Maureen E. Palmer, OTR, CIMT, is a certified Interactive Metronome provider and the Owner and Director of Focus Point Therapy, LLC. In Southfield, Michigan. Their web site is www.focuspointtherapy.com





PEDIATRIC DYSLEXIA CASE STUDY

“Ann” is a fourteen-year-old female diagnosed with dyslexia. For the past few years she had been in inclusion classes and receiving remedial reading with the reading specialist in her school district two times per week. She had completed the 4th level in the Wilson Reading Program and was not receiving remedial tutoring during the time that she was completing IM treatment.

At the initial pretesting session, the Gray Oral Reading Test-4 was administered to assess her reading rate, accuracy, fluency, and comprehension. Ann broke down in tears at her inability to read the simple passages, but she then collected herself and chose to continue the testing with a renewed strength and hope that Interactive Metronome (IM) treatment would be of value in helping her to read better. Ann found her hope in IM through the positive experiences of friend who had completed treatment the previous summer with a 1.5-year gain in reading comprehension fluency and comprehension.

Ann’s initial level of functioning in grade equivalency was a 1.4 in reading rate, 2.2 in accuracy, 1.4 in fluency, and >1.1 in comprehension according to the GORT-4.

After observing Ann’s stress from being confronted with her severe reading deficits on the GORT-4, it was decided to administer the IM pretest Long Form Assessment during a separate second session. Wearing headphones, Ann tried to match the rhythmic beat she heard with specific hand and foot motions using hand and foot triggers. The IM system used the data captured by the triggers to calculate and record how closely Ann was able to synchronize her motions to the rhythmic reference beat. The results were then displayed as a numerical score in milliseconds (ms) that provided a measure of her basic neurological and motor planning, sequencing, and timing capacities. Lower IM millisecond scores indicate better performance. Ann‘s performance on the IM Pre Long Form Assessment also demonstrated severe deficiency, yielding an overall score of 130.4 ms and a Super-Right-On (SRO) of 10.1%.

On the Attend Over Time Test, Ann’s performance demonstrated her difficulty with task vigilance, yielding an overall score of 155.0 ms and a SRO of 6%. This was also noted in her initial regular treatment sessions when same task scores worsened as the task durations increased.

Although Ann considered herself athletic since she was involved in both lacrosse and cheerleading at her middle school this past school year, she did not demonstrate the expected level of stamina for an athlete. Her eyes welled with tears over fatigue during the third through fifth sessions. However, she was determined to complete the sessions without reducing the task durations back to a level of comfort. The visual feedback component in the Interactive Metronome system helped keep Ann on task by providing the additional visual cues to help her monitor her taps. She was better able to “see” the early and late taps and to adjust her rhythm to synchronize with the reference tone. The use of the visual feedback component was gradually faded until it was no longer used after the sixth session.

Although she strove to meet the standards without modifications, some (such as reducing the number of tasks) were often made without Ann’s knowledge. Before the seventh session, she reported that she had begun freshman lacrosse camp at her high school with surprising adeptness in her ability to play the game. Her coach quickly assigned her to take charge of the drills at practice. Ann reported a dramatic improvement in her ability to catch the ball after it bounced off the wall with 100% accuracy, which replaced her previous performance accuracy of 40-45%. By the last session, Ann also made the varsity cheerleading squad and the competitive cheerleading squad at her high school. This was quite a feat for an incoming freshmen student. Her self-esteem was obviously boosted by her newfound performance ability.

Ann met her objectives by the fourteenth session with her task vigilance and Super-Right-On accuracy improving. She entered for her final Long Form Assessment with mostly quiet confidence but some hint of anxiety over her final performance ability. She quickly overcame her initial hesitancy once she began the tasks. Her final overall score was a 30.1 ms and a SRO of 40%, a 300% improvement.

Reading results from the GORT-4 test indicated an eight month acceleration in reading rate, two years in accuracy, 1.6 years in fluency, and most significantly, over 6.7 years in reading comprehension. Her therapist therorized that her newfound confidence in her abilities helped her to be less anxious at the presentation of the reading task and allowed her to achieve a score indicating a dramatic improvement in ability.

This case demonstrates the positive effect Interactive Metronome treatment can have on reading fluency and comprehension as observed by Ann’s gains. Only IM treatment took place for the weeks of intervention culminating with positive outcomes noted in attention, self-confidence, and sports agility and timing as well as dramatic gains in reading related areas.

For More Information: A growing number of practitioners in over 1,700 clinics, hospitals, and universities are using the IM program to improve their clients’ overall cognitive and physical functioning. To learn more about how to incorporate the IM program into your clinical setting, contact:

Interactive Metronome, Inc. Toll Free 877-994-6776 or visitwww.interactivemetronome.com

Barbara Fuoco-McCooley, MA CCC-SLP, is a certified Interactive Metronome provider and the Director of Innovative Designs for Educational Achievement, LLC in Moorestown, New Jersey. Their web site is www.innovative-educational-solutions.com.





DX: Non-Verbal Learning Disability Therapy: Traditional OT, ST & the Interactive Metronome (IM)

“At Abilities for Speech and Language (ASL) in Baton Rouge, Louisiana, we utilize Interactive Metronome (IM) treatment as a complementary approach to traditional Occupational and Speech-Language Therapy services for Children.”

The Interactive Metronome (IM) is a neuromotor therapy program that utilizes a highly adaptive technology to help individuals improve their underlying motor planning and sequencing ability. A study in the American Journal of Occupational Therapy (March/April 2001) reported that children who received IM treatment showed statistically significant changes in attention, motor control, language processing, reading, and ability to regulate aggression. We also observed improvements in motor planning, sequencing, timing, and processing speed for children with dyspraxia, developmental coordination disorder, learning disabilities, sensory processing disorders, and other related issues.

We currently have five certified IM providers on staff; two occupational therapists and three speech-language pathologists. This facilitates collaboration between both disciplines when tailoring IM sessions to meet a child's specific needs. Our training in Sensory Integration allows us to address critical underlying components of motor planning, such as arousal and rhythmicity. We employ a variety of individualized sensory strategies to obtain our clients' optimal performance.

CASE STUDY
A.J. is a ten-year-old boy with Non-Verbal Learning Disability (NVLD). A.J. is a bright and cooperative child with excellent parental support. A.J. was experiencing difficulties with fine motor skills, fluent writing and copying, attention, and organizational skills in the classroom. A.J.'s parents reported difficulties with motor coordination, resulting in limited participation in sports and extracurricular activities.

An Occupational Therapy evaluation was conducted using standardized assessments, clinical observations, parent/client interview, and review of writing samples from academic tasks. The Evaluation Tool of Children's Handwriting - Cursive (ETCH-C) was administered. Results revealed slow copying speed at 24 letters per minute from near-point and 19 letters per minute from far-point. Results of the Beery-Buktenica Developmental Test of Visual Motor Integration (VMI) were commensurate with reports of copying difficulties. VMI scores were delayed by 22 months. A.J. attained a raw score of 16 and a scaled score of 8, ranking his skills in the 23rd percentile.

A.J.'s fine motor skills were limited. He demonstrated difficulty with tasks requiring bilateral integration and sequencing (skipping, projected action sequences, jumping jacks, crossing midline). Bilateral integration and sequencing deficits are felt to be indicative of poor vestibular and proprioceptive processing. A.J. struggled to perform smooth, coordinated reciprocal movements. He relied heavily on vision to monitor his performance on motor tasks, especially writing. A.J. reported that he was unable keep up with peers in P.E. class when performing jumping jacks. He said, "Basketball is not a fun sport because no one will pass the ball to me."

A.J. received 24 sessions of Occupational Therapy. Various bottom-up treatment approaches were utilized to address motor planning, with emphasis on the vestibular, tactile, and proprioceptive systems. Multisensory techniques were utilized to address writing skills and visual motor integration. A.J. also participated in a cognitive program to enhance self-regulation, attention, and organization of behavior using sensory strategies.

A.J. responded well to intervention and made gains in all goal areas. Fine motor skills were reassessed at 6 months and showed progress. His confidence was also improving. Writing speed improved, but remained slow for his age. In the classroom, A.J.'s attention, organization, and sequencing were not optimal. It was determined that A.J. had not reached his full potential. After discussing the benefits of IM with A.J.'s parents, stressing that IM addresses the core components of motor planning, including sequencing and rhythmicity, we agreed that IM was the next logical step in A.J.'s treatment plan.

IM therapy was conducted over 15 sessions, 2-3 times per week. During an IM session, headphones and hand/foot triggers are used while the individual attempts to synchronize movements to a computer generated beat. Auditory guide tones progressively help the individual improve his/her accuracy. The computer produces a millisecond (ms.) score which allows the clinician to track the client’s progress. A.J. demonstrated significant difficulty with alternating exercises, as expected, due to the bilateral coordination difficulties demonstrated previously. Initially, lower extremity exercises were not fluid or coordinated and he was unable to use rocking movements. Due to poor body awareness, he frequently missed the foot trigger. He was unable to use his vision for backward in space exercises involving heels. When left to rely on tactile and proprioceptive input alone, he had difficulty returning to the starting point and tapping the trigger consecutively. A.J. was distracted by verbal praise and showed other indications of mild auditory hypersensitivity.

During IM therapy, individualized sensory strategies were employed to facilitate A.J.'s optimal performance. A mirror was used for visual feedback and a wall chart was used to help him discriminate and understand guide sounds. As time progressed, he relied less on these supports. His movements became more symmetrical and coordinated. According to his ms. score, A.J. had improved by 70%.

Upon follow-up testing, A.J. attained a VMI raw score of 20, scaled score of 10, and moved to the 45th percentile. ETCH-C results indicated dramatic improvements in speed. Near-point copying speed improved to 46 letters per minute, with far-point speed at 40 letters per minute. Clinical observations revealed significant improvements in bilateral coordination, specifically jumping jacks, stride jumps, cross patterns, and projected action sequences. Functionally, A.J.'s teacher reported "great improvement in handwriting." For the first time, he is able to ride a pogo stick and can do a front flip on his trampoline. He is joining more sports at school and participated in a community basketball league. He is also demonstrating improved coordination. A.J. can dribble a ball and has increased attentiveness during games. A.J. says, "IM was difficult for me, but now I can write a lot faster and play better defense!"

For more information:
A growing number of practitioners in over 1,500 clinics, hospitals and schools are using the IM program to improve their clients’ overall cognitive and physical functioning. To learn more about how to incorporate the IM program into your clinical setting, contact: Interactive Metronome, Inc. at 877-994-6776 or visit www.interactivemetronome.com Stacy T. Trouard, LOTR is an occupational therapist at Abilities for Speech and Language in Baton Rouge, Louisiana.



Adult Amputee


In December 2003, Brenda Canup crossed the finish line of the Disney Marathon; an amazing feat for anyone, let alone an amputee. But Brenda’s marathon run was even more amazing considering that a year earlier she could barley walk to her mailbox with the help of her walker. She attributes her success to the Interactive Metronome (IM).

Brenda was born with a deformity of her right foot and learned to walk with an awkward gait. Thanks to her older brothers who never expected less of her on the playground she managed to keep up with her regular daily activities. But as she grew older she knew that there were better options available.

After learning about advances in prosthetic limbs Brenda decided that it was time to take the next step. At age 35, she had a below the knee amputation and was fitted with a prosthetic leg.

Brenda’s surgery went well and she looked forward to walking more smoothly after therapy. But after four months of outpatient gait training she became depressed. Brenda experienced pain when trying to walk and still had not regained independent balance. Near the end of the outpatient regimen Brenda’s therapists were puzzled as to why she had not progressed past using a walker for ambulation. They noted that she became frustrated with the pain during therapy and often cried, thinking that she’d made the worst mistake of her life.

Her therapists at HealthSouth Sea Pines Rehabilitation Hospital in Melbourne, Florida were running a pilot program at that time for pediatric patients using Interactive Metronome (IM) and they suggested she try it. IM improves the underlying process of motor planning and sequencing, a core function of the brain that has shown to contribute to balance and coordination. IM was being used at Health-South Sea Pines to improve balance and gait in children with developmental disorders. The Physical Therapy director thought it was worth trying with Brenda.

Brenda approached the IM therapy skeptically. But after only three therapy sessions using IM Brenda was able to demonstrate independent balance. Her depression started to lift and her hopes rose. The improvements continued and she walked smoothly on her own for the first time. Before she knew it she was able to jog and immediately decided that she had to train for a 5K run. It was during that 5K training that Brenda was interviewed by Orlando, Florida’s NBC Affiliate, WESH Channel 2 TV news, about her amazing recovery. She told the reporter that her dream would be to run a marathon and, well…you know the rest of the story.

Thanks to Brenda and the innovative therapists who wouldn’t give up, IM is used across the country today in amputee, gait and balance clinics where the same types of outcomes continue to be seen.

For more information on how Interactive Metronome can help your patients get back on their feet, visit www.interactivemetronome.com or call 877-994-6776 to learn more.


Brain Injury

“Adam”, a 28 year-old male, was admitted to a brain injury program for cognitive rehabilitation at HealthSouth Outpatient Center at The Bridge. Two years earlier, he suffered an anoxic episode, seizures and went into a coma for two weeks due to adverse drug interactions.

Adam suffered a wide range of both cognitive deficits (impairments in auditory processing, attention to visual detail, verbal organization, written organization, attention, concentration, impulsivity, and generation of options for problem solving) and physical deficits (decreased balance, endurance, and coordination as well as weakness of the lower left extremity). In addition, Adam wears binaural hearing aids due to a loss of hearing as a result of the anoxic event.

During the initial clinical assessment, a speech-language pathologist on the treatment team administered both the Benton Controlled Oral Word Association Test to assess verbal organizational and fluency skills and the Championship Season subtest from the Ross Test of Higher Competency to assess written organizational skills. Adam scored in the 30th percentile on the Benton Controlled Oral Word Association Test and achieved 40% accuracy on the Championship Season subtest. In addition to full cognitive treatment for his brain injury, Interactive Metronome (IM) treatment was added to his program to address both his cognitive and physical deficits.

During the initial IM session, Adam’s occupational therapist demonstrated each exercise for him and then asked him to replicate it. Many of the exercises had to be adapted to Adam’s special needs resulting from his hearing and balance problems. He exhibited decreased attention span and lack of concentration and became easily frustrated with movements that involved his midline. His IM pretest assessment score indicated that severe motor planning, sequencing, and timing deficiencies were present.

Adam and his therapist established short term rehabilitation goals to increase the balance, endurance, and coordination of his lower left extremity and to decrease his impulsivity through the IM therapy.

Throughout treatment, the therapist noticed many improvements in Adam’s attention to visual detail, his attention/concentration, and his auditory processing skills. He became more organized in his daily life and was more open to suggestions and feedback from his treatment team. Most noticeable, Adam no longer demonstrated verbal outbursts and was able to refocus himself to tasks without cues from his therapist. He also demonstrated increased activity tolerance and appeared to walk more steadily.

Midway through IM therapy, the tests were administered again. Adam made a substantial improvement on the Benton Controlled Oral Word Association Test, increasing from the 30th percentile to the 92nd percentile. He also made a significant improvement on the Championship Season subtest increasing from 40% accuracy to 60% accuracy.

After the short-term rehabilitation IM goals had been met, his IM therapy program came to an end. Adam’s posttest score showed a 75% improvement from his initial pretest score.

He completed a Post IM survey on which he indicated that he is now better able to concentrate, focus, and understand key points more clearly. He also said that he is less impulsive more patient.

For more information visit www.interactivemetronome.com

Abbey Timpf, MOT, OTR/L, CTRS is an Occupational Therapist and IM provider, and Lorraine Clawson is the Senior Speech-Language Pathologist at HealthSouth Outpatient Clinic at The Bridge in Ft. Lauderdale, Florida. The Bridge is a community re-entry program for individuals with brain injury.

C4 QUADRIPLEGIC CASE STUDY

Michael is a 39 year old male with a diagnosis of C4 quadriplegia, onset 12/20/04, which occurred when he was struck on the back. His initial symptoms included mid back pain with quickly progressing right foot numbness, then loss of sensation to both legs up to the chest level. M. underwent cervical decompression and fusion.

M. was evaluated for PT and OT on 2/14/05. He wore a cervical collar and was wheelchair bound. M. was incontinent of bowel and bladder. His right arm strength was in the 4+ grade grossly. Left arm strength was 2- for shoulder muscles, 1 for biceps and supinator. Right leg ranged from 0 to 2- grossly. The left leg ranged from 2- to 3- grossly. He was dependent for bathing, house keeping and getting in and out of his house.

Interactive Metronome was initiated 4/26/05, when his arms and legs were strong enough to support his weight using a walker or loftrand crutches. He was able to walk with the crutches 180ft. in 9 min. 40 sec with minimal assistance using a 4 point gait pattern. He performed transfers in and out of his wheelchair with close supervision. Interactive Metronome was modified to allow sitting when using the hands, standing with a walker, placing a wedge under the foot trigger to allow for weak dorsi-flexion and hitting the foot trigger every other beat.

Patient goal: walk unassisted.

Treatment #1
M. tolerated up to 70 repetitions of both hands, with the trigger on his dominant, less affected right hand. All lower extremity exercises were performed hitting every other beat, using a walker and heavy support of both hands when performing all leg exercises.

Treatment #2
Goal- facilitate abdominal contractions and trunk stability, increase left arm strength and supination. M. sat on physioball with light support of therapist when performing both hands. M. placed the hand trigger on the non-dominant left hand to emphasize increased left hand movement and supination. He worked on increasing endurance of legs and arms.

Treatment #3
Goal- facilitate trunk stability and dorsi-flexion, and speed of legs. M. sat on physioball and performed alternating toe exercises, hitting every beat. He continued to work on endurance of hands and standing. When working on endurance high goals were set, allowing short rests as required.

Treatment #4, 5 & 6
Goal- improve standing balance without support, facilitate reciprocal patterns, facilitate weight shifting. For hand exercises M. stood close to the table with the walker in front of him and a chair behind him in case of loss of balance. He performed both toe exercises, raising the opposite arm simultaneously to touch a box on the table to simulate reciprocal walking and arm swing. Two hand triggers were used, placing each on a box on either side of the IM computer. M. hit the triggers, crossing midline to facilitate trunk rotation and stability when standing.

Treatment #7
Goal- facilitate weight shifting, and narrowing base of support. M. performed both toes, crossing midline, hitting the foot triggers on either side of him.

Treatment #8
Goal- improve weight shifting, prepare pt. for axillary crutches, and facilitate heel strike. The foot triggers were placed on both sides of M. He hit alternating foot triggers, facilitating hip abduction and performed simultaneous toes and opposite hands to boxes placed on table to simulate walking with an arm swing. The foot trigger was placed in front of M. He hit alternating heels, instead of toes to simulate heel strike.

Treatment #9
Goal- improve trunk stability and balance, increase left arm supination, and general strength and endurance. Until this time, M. depended on a walker for support during foot exercises. A PVC pipe was substituted to increase demand for trunk stability. A one pound weight was placed on the left wrist during bilateral hand exercises. M. attempted to use a body blade with his right arm, while performing left toe taps to the foot trigger for a short duration to challenge his timing.

Treatment #10, 11 & 12
Goal - improve balance standing on feet and facilitate weight shifting back and forth and laterally. Foot triggers were placed in front of and behind M. He alternated hitting right foot forward, left foot behind, then switched feet, using axillary crutches for support. M. continued to work on leg exercises, stabilizing himself with a PVC pipe only. M. straddled one foot trigger, placed between his legs. He hit alternating toes, using crutches for support. Using two hand triggers, on either side of the computer table, M. stood unsupported for the first time. He hit alternating triggers with the opposite hand, crossing midline and shifting his weight.

Treatment #13
Goal- improve balance and lower extremity strategies for appropriate responses to quick stimuli. M. held two PVC pipes (one in each hand) for stability. Two foot triggers were used, one with a green dycem pad placed on it, the other with a blue pad. The therapist stood behind the computer, holding up either a green or blue paddle. The patient tapped the corresponding foot trigger.

M. was discharged to independent living, without ramp to his home or other assistive devices except small based quad cane on 5/27/05 after 14 IM sessions.

At discharge he was independent with all self care activities including showering and dressing, all wheelchair transfers, meal preparation, laundry, dishes, and house cleaning. He is independent getting in and out of his home which requires 3 steps to enter with bilateral hand rails.

He walked without any assistive device 180 feet with contact guard assist and occasional minimal assist for balance in 7 min.

Michael stopped in to say "hi" on 8/18/05. He was walking with a near normal gait without an assistive device.




IM HELPS STROKE PATIENT WITH ADLs


John W. is a 47-year-old Kansas man with no prior health concerns. Both he and his family were devastated when he suffered a CVA last October. After being discharged from the acute care hospital and inpatient rehab program, he was referred to Kansas Rehabilitation Hospital where he could access specialized rehabilitation services.

As a father of four teenagers and the breadwinner for his family, John was very anxious to do everything he could to regain his independence with daily living skills and mobility that were reduced by a significant left upper extremity tremor, left-sided spasticity, poor standing balance and a decreased ability to sustain his attention to complete challenging functional tasks.

When he started his outpatient therapy program, John required assistance from his wife to complete basic self care tasks and he was forced to have a family member with him at all times because of unsteadiness with his gait. He was dependent for all Instrumental ADL tasks?including use of the phone.

When John’s Speech Therapist suggested that he would benefit by participating in the Interactive Metronome (IM) program because of his difficulty processing, he was curious to find out more. Prior to his first IM session, John’s family went to the Internet, as directed by his therapist to get more information (www.interactivemetronome.com). After learning more, John and his family decided it would be a good idea to try IM.

So, three times each week, John’s treatment included IM. During each session, he stood in front of a computer with a pair of headphones on. A metronome beat was heard through headphones and visual guides were displayed on the monitor. John was prompted to match each beat with a variety of hand and foot movements, including crossing midline. The program measured to the millisecond how closely he matched the beat.

As each session progressed, John got closer and closer to the beat. As his score was improving, the neural pathways in his brain were strengthening enabling his mental processing speed to increase. As his processing speed increased, so did his balance and coordination. The improvement in his executive functioning became obvious. A ripple effect began in John’s progress.

John and his wife could see the obvious changes in his timing by reviewing the data during and after each IM session with his therapist and comparing his performance to previous sets of exercises completed. The physical assistance he required to maintain his balance decreased while performing all of the IM exercises in a standing position. He was also able to concentrate and attend to the IM exercises for extended periods of time. The gains John could see by reviewing the IM data were confirmed by a variety of objective timed coordination tests and ADL scales used to measure John’s progress throughout his rehab program.

After 19 IM sessions, John was discharged on January 13th, 2005 with the following gains:

Managed his medication and checkbook on his own
Prepared meals (breakfast and school lunches)
Removed clothes from the dryer, folded them and put them away
Independent use of both house and cell phones
Used vacuum at home without loss of balance
Used a grocery cart and retrieved items from various shelf heights without loss of balance

On February 1, 2005 John successfully passed his driving evaluation and began driving again. He even returned to work full time. John had met his goals and is happy to be back to his normal routine.

The Interactive Metronome is a mainstream therapy tool that engages patients and drives them to improve their rehabilitation outcomes. It is used in over 2,000 hospitals and clinics throughout the United States and Canada. To learn more about IM visit www.interactivemetronome.com or call 877-994-6776 (U.S. Only) or 954-385-4660.

Karen Farron is an Occupational Therapist at HealthSouth Kansas Rehabilitation Hospital in Topeka.


Adult Traumatic Brain Injury Case Study

About Darren
Darren is a twenty-year-old male who sustained a closed-head injury with multiple fractures from a motor vehicle accident approximately five months ago. He apparently had a hypoglycemic episode while driving and blacked out. Darren is also diabetic and due to his stay in a hospital bed, he developed a heel ulcer. After about two months, Darren was then admitted to a comprehensive brain injury program. Through cognitive assessments and evaluations, it was found that he has impairments in the following areas: organization/planning, attention/concentration, immediate and delayed recall of verbal information, and written organization. At the time of his admission to the program, Darren was under toe-touch weight-bearing precautions due to his fractured hip and right heel ulcer, and he was ambulating with a walker. He also reported a rating of 3 out of 10 regarding pain in his right lower extremity. Darren began Interactive Metronome treatment as an added treatment tool to address the cognitive deficits and to help progress him physically with his right lower extremity as his weight bearing precautions are lifted.

Initial Evaluation
Once admitted to the brain injury program, Darren went through a series of evaluations given by the speech pathologists and the occupational therapists. The Benton Controlled Oral Word Association Test was given to assess his verbal organization skills, and he scored within the 58th percentile. The Championship Season Test was administered to assess his written organization skills, and he scored a 0%. The Babcock Story Recall Test was given to assess his immediate recall of verbal information, and he scored in the 21st percentile. Through the community living skills evaluations administered by the occupational therapists, it was found that Darren had difficulty with organizing/planning, attention to visual detail, and attention/concentration. The focus of Darren’s goals for the first month’s treatment included immediate recall of verbal information, written organization, verbal organization, and the use of strategies.

An IM Pre Long Form Assessment was also administered. Darren had to complete the exercises in a sitting position and was unable to complete exercises involving the right foot due to his strict toe-touch weight-bearing precautions. After the occupational therapist demonstrated each individual exercise, he was able to mimic the movements with minimal cuing. He was only able to complete 8 out of the 14 tasks due to the physical restrictions. During this assessment, it was noted that Darren became easily distracted and began talking tangentially in between each task. It was also noted that Darren was able to get himself into a rhythm fairly quickly. The results of the assessment (shown below) fell in the “Below Average” range according to the IM Indicator Chart.

Development and Execution of an Individual IM Treatment Plan
A treatment plan was developed based on Darren’s individual needs, test results, and the transdisciplinary team’s observations of him during treatment sessions. The provider identified that Darren liked to be challenged and was motivated to return to college. The IM treatment plan involved increasing the repetitions steadily to work on Darren’s attention/concentration. The plan was to work on the tasks that involved mostly the upper extremities and the left foot due to his lower-right extremity precautions, and then as the weight-bearing precautions were lifted, he could begin using the lower-right extremity as well as completing tasks in a standing position.

The beginning IM goals established by the provider were to make any necessary modifications to the program to accommodate Darren’s weight-bearing status as well as familiarize him with the movements and guide sounds. Darren’s IM treatment began with exercises 1-4 and 9 with a total duration of almost 19 minutes (1000 repetitions), just under four minutes (200 repetitions) each. He was able to learn the guide sounds within the first few treatment sessions and demonstrated the ability to adjust his movements accordingly. By the next session, he was able to tolerate tasks totaling nearly 26 minutes (1400 repetitions).

Darren established a few personal goals that he would like to accomplish through the IM program including increasing his attention/concentration, timing, and overall activity tolerance.

Interim Testing and the Next Phase
After completing five sessions, an Interim Long Form Assessment was completed to review Darren’s improved weight-bearing ability and to assess his IM progress thus far. He was now able to complete 11 out of 14 tasks, several of them in a standing position. His unadjusted overall millisecond score was 46.5 and his SRO was 27.3%. During the next five sessions, he continued to require cuing between exercises to stay focused due to his tendency to carry on tangential conversations.

Through observations made by the provider, it was determined that the typical 13-15 sessions were not going to be sufficient for Darren to benefit fully from the IM treatment program. Another Interim Long Form Assessment was completed after the twelfth session. His unadjusted millisecond score was 40.7 and his SRO was 28.6%. He was now able to complete more of the tasks in a standing position, holding onto a chair to assist with his balance. The treatment team was beginning to observe some improvements such as Darren becoming less fidgety during his social interactions with other clients as well as less tangential with his speech. The IM treatment was also helping him get used to weight bearing. Prior to IM treatment he had not been putting much weight on his foot. At that point, he set goals for himself including the completion of all tasks in a standing position and an increased number of bursts. The provider set goals to work on the exercises that he had more difficulty with as well as to reach 37 minutes of IM tasks (2,000 repetitions) in one session involving several different tasks to increase his ability to attend over a longer period of time.

Concluding Evaluation
Once Darren met his personal goals and the goals established by the provider, the IM Post Long Form Assessment was completed. The results are listed in the chart below:

Darren’s Thoughts
Darren felt the IM program had helped mostly with his concentration. At first, he felt the program would be easy but soon realized it was challenging and looked forward to the sessions each week.

Conclusion
Although Darren continues receiving treatment through a comprehensive cognitive program for his brain injury, it appears that the IM program had been a good asset to his treatment and progress.

Darren was an unusual case in which the program needed to be modified to accommodate his weight-bearing precautions, allowing him to progress to a standing position once the precautions were reduced. He continued to be under partial weight-bearing status until after he completed IM treatment. He was also able to tolerate the steady increases in repetitions well. Overall, Darren responded well to the challenges the provider presented with each IM treatment session.

(영문)

Introduction

Interactive Metronome(IM) is a developmental and learning rehabilitation program used by therapists to improve:

Cognitive Deficits
Attention & Concentration
Motor Planning & Sequencing
Language Processing
Behavior (Aggression & Impulsivity)

Physical Deficits
Balance & Gait
Endurance
Strength
Motor Skills
Coordination

Patients who may experience positive results from IM include those with:
Sensory Integration Disorder
Asperger Syndrome
Autism Spectrum Disorder
ADD/ADHD
Cerebral Palsy


How IM Works

The Interactive Metronome is an advanced brain-based assessment & treatment program developed to directly improve the processing abilities that affect motor planning and sequencing. Motor planning and sequencing are central to human activity ? from the coordinated movements needed to walk or climb stairs, to the order of words in a sentence to provide meaning. Interactive Metronome (IM) is the only therapy tool that improves those human capacities by using innovative neurosensory and neuromotor exercises developed to improve the brain's inherent ability to repair or remodel itself through a process called neuroplasticity.


Clinical Foundation
The human brain's efficiency and performance depend on the seamless transition of neuronetwork signals from one area of the brain to another. Findings in a recent study by Neal Alpiner, MD, “Functional MRI Study of the Effects of IM on Auditory-Motor Processing Networks”, suggest that IM works by augmenting internal processing speed within the neuroaxis. The key regions affected appear to include the cerebellum, prefrontal cortex, cingulate gyrus and basal ganglia.

The IM program provides a structured, goal-oriented process that challenges the patient to synchronize a range of hand and foot exercises to a precise computer-generated reference tone heard through headphones. The patient attempts to match the rhythmic beat with repetitive motor actions.

A patented audio or audio and visual guidance system provides immediate feedback measured in milliseconds, and a score is provided.

Over the course of the treatment, patients learn to:

Focus and attend for longer periods of time
Increase physical endurance and stamina
Filter out internal and external distractions
Improve ability to monitor mental and physical actions as they are occurring
Progressively improve performance

The Interactive Metronome is an advanced brain-based treatment program designed to promote and enhance brain performance and recovery. This is accomplished by using innovative neurosensory and neuromotor exercises developed to improve the brain's inherent ability to repair or remodel itself through a process called neuroplasticity.


Occupational Therapy

For many years, occupational therapists have observed the significant role that motor planning and sequencing play in helping patients become more functionally independent in the activities of daily living (ADLs).

Published research shows that improving rhythmicity and timing through Interactive Metronome (IM) may also result in significant improvements in the development of cognitive and physical skills that are important for performance in many areas including:

Motor function
Bilateral coordination
Sensory integration
Motor planning and sequencing
Balance

According to an article published in the American Journal of Occupational Therapy entitled "Theoretical and Clinical Perspectives on the Interactive Metronome ? A View from Clinical Occupational Therapy Practice," “Many of the individuals [who] occupational therapists evaluate from a sensory integrative frame of reference are ‘out of sync’ with the spatio-temporal aspects of their environments. They often lack the internal sense of timing that is necessary to regulate sleep as well as physical and social interactions with the world. In addition, they often have difficulty with visuospatial and constructional skills that are highly dependent on accurate perception of temporal and spatial cues."

"Clinical experience suggests that if IM is used as a technique along with sensory integration, there may be an improved ability to more fully benefit from the sensory integration approach. If IM is done when no further gains are seen with a sensory integrative approach, it is possible that IM may be effective in creating further gains."


Speech Therapy

Practitioners in the field of speech-language pathology recognize the role of motor planning and sequencing in the acquisition of speech, language, communication skills, and cognition.
IM is a unique application of technology that can improve those underlying capacities, which are essential to patients’ development of speech-language and cognitive skills. Through neuroplasticity, the cognitive-motor exercises that make up IM tasks stimulate the brain to adapt or create new neural pathways that compensate for injury or developmental delay, which results in functional outcomes.

IM can result in or contribute to improvements in:

Language processing
Social communication
Planning and sequencing
Attention and concentration
Control of impulsivity and aggression


Physical Therapy

Physical therapists use Interactive Metronome to assess and improve patients’ motor planning and sequencing. This interactive process enhances the patient’s mobility and gross motor function, which helps him/her become more functionally independent.

The IM program involves repeated hand, toe, and heel exercises as well as weight shifting, and bilateral lower extremity coordination. These exercises are performed during therapy visits and are increasingly varied and extended so that most patients are able to perform thousands of repetitions. Since the treatment provides engaging feedback and requires a high level of concentration, it provides the patient an opportunity to maintain a level of endurance not typically reached other repetitive exercises.
Those with limb amputations and other balance-related diagnoses are also helped by the repetition of IM exercises, which bring about progressive improvements in their balance and gait. Functional motor control gains are achieved within a short period of time.
IM neurological and motor rehabilitation helps improve patients’:

Endurance and strength
Gait Symmetry
Coordination
Motor skills
Balance


University

Creighton University Medical Center
Medical College of Georgia (MCG Health)
Rusk Institute (NYU)
University of North Carolina
University of Notre Dame
Duke University
Louisiana State University
University of Kansas Medical Center
University of Rochester
East Carolina University
Arizona State University
University of Washington
The University of Utah
College of Staten Island
Cerritos College
Nova Southeastern University
Youngstown State University
Widener University
Marquette University
Boston University
Grand Valley State University
University on Nevada
University of Miami
Johns Hopkins University
MCP - Hahnemann University
Texas Womens University
California State University
Rider University
Richard Stockdon College


Case Study

Sensory Integration Disorder
A.E., a nine-year-old girl diagnosed with Sensory Integration Disorder, exhibited poor fine motor coordination and balance and had a history of multiple tantrums each day. She also had a D average in math. After 5 weeks of IM training, her parents reported A.E. riding her bicycle without training wheels for the first time. Her concentration had improved dramatically, and she earned an A and B on her next two math tests. Her parents also reported a drastic decrease in the frequency and duration of her emotional outbursts.

Leg Prosthesis and DCD
J.G. was born missing the portion of his right leg below the knee, with dislocated hips, and without ligaments in his left knee. Additionally he suffered from Developmental Coordination Disorder (DCD). He had severe motor deficits and poor balance and coordination. As a result, he often fell. He walked awkwardly and only with the use of his walker. At age 8, J.G. participated in IM treatment. During the early sessions J.G. showed dramatic progress with hand coordination but was easily frustrated by his balance deficit. After focusing his treatment on the use of his prosthesis, J.G. was soon shifting his weight with ease and could alternately tap his toes without holding on to anything for balance. Within a short time, J.G. could walk with ease without using any assistive devices. After IM, he began playing basketball, football, and soccer with his brothers for the first time.

Asperger Syndrome
An eight-year-old male diagnosed with Asperger Syndrome was referred for Interactive Metronome training. This otherwise healthy patient had difficulty completing tasks, following directions, and cooperating in a group environment, and he often displayed tantrums. After completing treatment, he demonstrated improved transitioning, greater independence, decreased frustration, and reduced tantrums (both in number and intensity).

ADHD & Learning Disabilities
D.C. was 5 years old when she was diagnosed with ADHD and severe learning disabilities. She had demonstrated poor attention and concentration and had great difficulty processing multiple instructions. At age 8, she was enrolled in IM treatment. During her first visit, her therapist reported, “She was bouncing off the walls. She got in the chair and tried standing on her head.” After two weeks of IM treatment, she sat down and read her mother a book. D.C. was able to sit quietly for up to 20 minutes. “I couldn’t believe this was my child,” her mother stated.

Amputee
B.C. had an amputation at age 35. After her BKA, she underwent intensive inpatient rehabilitation as well as four months of traditional outpatient rehabilitation with poor outcomes. She could not walk without assistive devices and experienced pain and depression. After undergoing thousands of IM repetitions, she experienced increased motor control, regained her balance, and developed a smooth and symmetrical gait. Within eight months of IM therapy, B.C. ran and completed a full marathon.

Autism
Derek was eight years old and affected by Autism. Before taking going through Interactive Metronome ®, he had extremely poor motor planning capabilities and severe ADD. At first, Derek was unable to perform most of the IM exercises or scored in the lowest percentiles, and he was unable to complete a session due to exhaustion. Yet within a month, his motor planning and coordination began to improve steadily. After six months the changes were dramatic. Derek became more social, his coordination improved and he began to enjoy and participate more actively in sports and physical activities. His ability to focus improved so much that his teachers thought he had begun taking a new medication.

Traumatic Brain Injury (TBI)
D.S. suffered a TBI in a car accident when he was 19 years old. After years of therapy, he was able to relearn primary gross motor and speech functions but displayed very jerky motions, an unstable waddle-like walk, and a severe speech stutter. At age 38, D.S. underwent IM treatment. By the time D.S. had completed his sixth IM session, he had significantly improved precise gross motor control of his arms. Upon completing the program, D.S.'s physician remarked, “D.S.’s dramatic overall improvement over a period of only five weeks is absolutely amazing.”

Cerebral Vascular Accident (CVA)
A 46-year-old mortgage manager sustained a CVA and presented with a vestibular disorder. He suffered from severe dizziness during head and eye movement, mild problem-solving difficulties, pronounced ataxic gait, poor coordination, jumping difficulties, and loss of balance. After 11 sessions with the Interactive Metronome, the patient performed all advanced balance skills with improved coordination. For example, he could jump and perform jumping jacks without loss of balance and his incidents of dizziness decreased significantly. He became more independent and displayed improved executive level problem-solving skills.


Research

ADHD Study
A double-blind, placebo-controlled study of 9 to 12-year-old boys diagnosed with ADHD found those undergoing IM treatment showed significant patterns of improvement in attention, coordination, motor control, language processing, reading and control of aggression/impulsivity. This study was published in the American Journal of Occupational Therapy, March 2001.

Motor Control Study
In a study by P.M. Stemmer, “Improving Student Motor Integration by use of an Interactive Metronome,” presented at the 1996 Annual Meeting of the American Educational Association in Chicago, IL, a comparison of a group of special education students who received treatment with IM to a control group showed that the IM group improved significantly in both motor control and motor coordination as evaluated by independent measures (Bruininks-Oseretsky and SIPT Motor Accuracy Test). Parents of the IM group members also reported marked improvement in their children's ability to attend to tasks, read, and write as well as in their general behavior.

Timing in Child Development Study
A correlation study of 585 children in a public school district found significant correlations between IM score and academic performance in reading, mathematics, language, science, social studies, and study skills. The researchers concluded that timing and rhythmicity play a foundational role in the cognitive processes underlying performance in these academic areas. The results were published by the High/Scope Foundation, a non-profit educational research institution.

Academic Fluency Study
More than 1500 middle and high school students were pre-tested using selected subtests of the Woodcock Johnson III (WJ III) standardized test. The students then received 12 one-hour sessions of IM. When the IM treatment was complete, the students were post-tested using the same subtests of the WJ III. Analysis of the aggregate results showed statistically significant increases in students grade equivalent (GE) performances in the following areas:

Reading Fluency increased by 2.25 (GE)
Math Fluency increased by 1.7 (GE)

High School Academic Study
The largest public school in Florida conducted a controlled study of 360 ninth and tenth grade students to examine the correlation between improvements in students' timing and academic achievement. Post-test results showed the IM group scored significantly higher in broad reading and reading fluency as compared to the Control Group. Those students' math calculation skills, math fluency, and attention also improved significantly.

Title I Study
This study involved fourth and fifth grade students identified as Title I eligible and scoring in the lowest three stanines on the reading subtest of Stanford Achievement Test Edition Nine. Forty of the students participated in 12 sessions of IM training. Forty other students formed the Control Group and were matched to Research Group students on the basis of School Ability Index scores from the Otis Lennon School Ability Test.

The Research and Control Groups were both pre-and post-tested with the Woodcock Johnson III reading and math fluency subtests. The Research (IM) Group achieved significantly higher post-test reading fluency performance (1.67 grade equivalency higher) than did the Control Group.
The STAR reading assessment was also administered pre-and post-training. The results of the IM-treated students demonstrated increases averaging one to two grade levels.
The students' pre and post-training Stanford Achievement Test Ability-Achievement Comparison (AAC) range standings were also reviewed. As a group, the students in the IM Group increased their AAC range standing from Low (achievement is below ability) to Middle (achievement is at ability level) or High (achievement is above expectations). The Control Group, on the other hand, either remained at the Low or Middle range or decreased from Middle to Low. *Title I is the largest federal aid program for elementary and secondary schools.

Parkinson's Pilot Study (Full Article pending publication)
This pilot study examined the effect of computer-based motor training activities upon the severity of signs and symptoms in patients with mild or moderate Parkinson’s disease. Methods: Thirty-six subjects were randomly assigned to train using the Interactive Metronome (IM) device, which provides training for rhythmicity and timing, or to a control regimen consisting of motor activities directed by a rhythm or a computer (e.g., clapping or exercising to music or to a metronome tone or playing computer games). The severity of parkinsonism was compared before and after 20 hour-long training sessions as measured by the Unified Parkinson’s Disease Rating Scale (UPDRS) part 3 and, as secondary measures, the UPDRS part 2, the Hoehn and Yahr stage, a timed finger tapping test, and the timed “Up & Go” test. Results: Twelve subjects completed training with the IM device and nine completed the control regimen.
In this controlled pilot study, computer-directed movement training, both with the IM device and with the control training activities, was found to improve the motor signs of parkinsonism, both on clinical examination (UPDRS part 3) and in objective timed tests (finger tapping and the timed “Up & Go” test). This is the first direct demonstration that these types of exercises can improve parkinsonism, lending support for the phrase “use it or lose it” that is often quoted to patients. Non-pharmacologic interventions such as these are highly attractive to patients, and they help to foster a sense of higher personal control over the disease. The use of such interventions is generally embraced by patients with Parkinson’s disease.