Vestibular: Over Responsive

1. Student refuses to participate in P.E. and playground games

Some students refuse to participate in P.E. and playground games because they dislike the sensation of the movement involved. They will particularly dislike fast movements (e.g. being pushed in a play car), backwards movements (e.g. on a swing) and spinning movements (e.g. on a roundabout). They may also dislike sudden changes in movement and so will avoid chasing games and many team sports.

Suggested strategies:

• Provide alternative games and activities in P.E. and the playground which do not involve fast, unpredictable movement
• Encourage the student to participate in activities which involve up/down movements and this is easier to tolerate than backward or spinning movements
• Examples of suitable P.E. and playground activities may include:
  • Jumping e.g. star jumps
  • Hop scotch
  • Skipping
  • Walking
  • Throwing beanbags at a target
  • Throwing/catching a ball
  • Treasure hunt e.g. hide items in the playground and give the student the list of items to find
  • Nature trail e.g. give the student a list of natural items to find in the playground, such as a leaf, blade of grass, daisy
• Set up a games room in school for break and lunchtimes and provide a range of board games as an alternative to playground activities

Point to remember

• Engage student in physical activities which do not involve fast or rotary movements

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2. Student refuses to use PE equipment e.g. wall bars, ropes, gym horse, balance beam

Students may refuse to use equipment which involves feet being off the ground as they experience gravitational insecurity. Using equipment such as wall bars and ropes will significantly increase anxiety and they may feel dizzy and nauseous. This will result in a refusal to participate in P.E.

Suggested strategies:

• If using the balance beam to work on balance, use alternative equipment and activities:
  • Balance activities on the ground to provide a firm base of support e.g. standing on one leg, hopping, walking tiptoe along a line taped to the ground
  • As the student becomes more confident, they may be able to walk along lower equipment with a wide surface e.g. a bench
  • The student may be able to tolerate sitting on a gym ball if feet are on the ground. Encourage reaching to each side (e.g. to throw beanbag to a target) in order to develop balance.
  • Jumping on a small trampette or trampoline will improve balance. A student with gravitational insecurity may initially need to hold onto a bar.
• If using the ropes to work on upper body strength, use alternative equipment and activities:
  • Pulling along a rope while lying on tummy on the floor. This requires the same reciprocal movement and upper body strength as climbing vertical ropes.
  • Wall push ups
  • Crawling e.g. set up an obstacle course so child crawls under, over and through obstacles; or child carries beanbag on back from one end of room to target at other end
  • Wheelbarrow walks e.g. set up races
  • Lying on tummy on a bench and pulling self along
  • Press-ups, either on hands and knees (for those with limited core strength) or on toes
  • Weight lifting
  • Tug of war
  • Hitting a ball with a bat
  • Throwing and catching balls of increasing weight
• If using the wall bars to work on strength and motor planning, use alternative equipment and activities:
  • Obstacle courses e.g. jumping along mats, crawling through a tunnel, climbing over a bench. This will improve motor planning.
  • Crawling- this uses the same reciprocal movement and core strength as climbing wall bars.
  • Wheelbarrow walks
  • Scooter board– this improves core strength, upper limb strength and motor planning. A student who is sensitive to movement will prefer to control the speed and direction of movement of the scooter board.
• If using the gym horse to work on core strength and stability, use alternative equipment and activities:
  • Activities lying on stomach and propping up on elbows to complete an activity e.g. rolling a ball to a partner, rolling a ball to skittles
  • Commando crawling i.e. pulling self along floor on stomach
  • Activities in tall kneeling position e.g. throwing and catching a ball, throwing a ball to a target
  • Activities in half kneeling position e.g. throwing and catching a ball, throwing a ball to a target
  • Crawling e.g. set up an obstacle course so child crawls under, over and through obstacles; or child carries beanbag on back from one end of room to target at other end
  • Scooter board e.g. student propels scooter board in/out cones; student propels scooter board from one end of room to the other, picking up as many beanbags as possible along the way. A student who is sensitive to movement will prefer to control the speed and direction of movement of the scooter board.
  • Sitting on gym ball and throwing beanbags at a target. Ensure the student’s feet are on the ground while sitting on the gym ball to reduce anxiety.
  • Lying on stomach over gym ball and maintaining balance through arms. A student who has gravitational insecurity may refuse to participate in this activity and should not be persuaded if showing reluctance and anxiety.

Point to remember

• Avoid activities which involve equipment at a height

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3. Student will only engage in sedentary activities

Students who are overresponsive to movement will often avoid all movement activities and instead select more sedentary activities e.g. reading, computer games. It is important to engage them in some physical activities to promote physical and emotional wellbeing and to encourage interaction with peers.

Suggested strategies:

• Offer a range of activities which only involve gentle movements and do not incorporate fast movement, unpredictable movement, backward movement or spinning. Some ideas may include:
  • Throwing/catching/kicking ball with partner
  • Throwing/kicking ball to target
  • Going for a walk
  • Treasure hunt e.g. hide items in the playground and give the student the list of items to find
  • Nature trail e.g. give the student a list of natural items to find in the playground, such as a leaf, blade of grass, daisy

As the student becomes comfortable in these activities, you may be able to gradually increase the movement required e.g. instead of kicking ball to target, involve the student in a football game with a small number of classmates; running around the treasure hunt instead of walking

• Provide the student with a choice of activities as this often improves motivation and participation. Choices can be presented on a visual choice board.
• Use visual strategies to explain what it expected in an activity as this may also increase participation e.g. visual work system, written instructions
• Use turn taking games so that the student is not constantly involved in movement; he will have a break from movement while waiting his turn
• Provide a calm card so the student can request a break from the movement activity if he is feeling overwhelmed.
• If the student refuses to engage in movement games in the playground, he may engage in more purposeful activities which have a clear function. Use activities which incorporate some physical movement. Examples may include:
  • Gardening
  • Brushing paths
  • Setting out materials and books for classes after Break and Lunch
  • Tidying away materials and books
  • Delivering mail from the office to classrooms
  • Helping to move furniture, stack chairs etc

Point to remember

• Offer student a range of activities which involve gentle movement only.

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4. Student is distracted and/or fearful when sitting on a chair or toilet which is too high i.e. feet are off the ground

A student who experiences gravitational insecurity becomes fearful when feet are not on a stable surface. In school, these negative responses may be observed if the student is sitting on a chair or toilet which is too high.

Suggested strategies:

• Ensure the student is sitting on a seat of the correct height so that both feet are on the ground and his/her back is against the back of the chair. This is also essential for correct posture which then facilitates improved fine motor skills e.g. handwriting.
• If the student needs to sit on a higher chair in order to be at the correct height for the desk, provide a box or step on which he can set his feet. These are commercially available and can be attached to classroom chairs. Alternatively, a small box may be appropriate but consider health and safety factors i.e. risk of child tripping over it when not seated.
• Provide a step at the toilet so that student can set feet on firm base of support if toilet is too high. This can be permanently fixed to the floor, or be moved into place when required.

Point to remember

• Ensure student always has a stable base of support e.g. footrest at chair and toilet if required

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5. Student has regular episodes of motion sickness

Students who are sensitive to movement often experience motion (or travel) sickness. They may be ill on the bus, or they may arrive to school feeling nauseous. Fast speeds and frequent changes of direction and frequent stop/starts increase feelings of motion sickness.

Suggested strategies:

• Student carries out head compressions during and after the journey.
• Student is taught to look straight ahead and fix on a static point.
• Student is allocated a seat at the front of the bus where he/she has a clear view through the windscreen.
• Use of a weighted item can reduce motion sickness during travel but it is essential that this is assessed and monitored by an appropriately qualified occupational therapist.
• If possible, arrange for the student to be collected towards the end of the bus run and left home near the start of the bus run in order to reduce the length of the journey.

Discuss with a pharmacist who may be able to recommend alternative methods to address motion sickness.

Point to remember

• Consider where student is seated in the bus; ensure he/she can look at a point straight ahead

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6. Student complains of headache and nausea hours after engaging in movement activities

A student who is overresponsive to vestibular input can experience negative effects up to several hours after engaging in movement activities. The student may report a headache or feelings of nausea after using moving equipment such as swings or roundabouts.

Suggested strategies:

• If the student is complaining of nausea, dizziness or headache, allow him/her to lie down in a quiet area until feeling better. If the student continues to feel unwell, contact a doctor.
• Direct the student to carry out some deep pressure activities to reduce feelings of nausea, dizziness and headache. Examples may include:
  • Head compressions
  • Wall pushups
  • Hand pushes
• In future, do not allow student to use moving equipment as his/her vestibular system is unable to cope with the movement sensations. Direct the student to use alternative equipment, such as the climbing frame or slide. A student who has gravitational insecurity is likely to avoid all playpark equipment so allow them to engage in other activities such as walking or ball games.
• If you know the student has movement sensitivity and has been using playpark equipment, inform the parents so they can monitor for nausea and headache at home.

An occupational therapist qualified in Sensory Integration assesses and provides intervention for vestibular overresponsiveness.

Point to remember

• Use proprioceptive input (e.g. press ups, head compressions) if student complains of nausea or dizziness after a movement activity. See section on Proprioceptive system.

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7. Student in wheelchair is fearful when wheelchair is moved backwards or tilted backwards

Some students in wheelchairs are overresponsive to movement. In particular, they may respond fearfully when the wheelchair is moved backwards or turned.

Suggested strategies:

• If the student is able to propel their own wheelchair, do not move it for him/her.
• If the student is unable to propel the wheelchair, ensure you prepare him/her for all movement.  Avoid unpredictable and sudden movement of the wheelchair.
• When pushing the wheelchair, use a forward movement as much as possible rather than backward movements.
• Use ramps and dropped kerbs where possible rather than tilting the wheelchair backwards.
• If you need to tilt the wheelchair to negotiate a step or kerb, prepare the student for this movement instead of suddenly tilting the wheelchair backwards.
• Always move the wheelchair slowly, and when turning it or changing direction, ensure this is done slowly. Avoid fast movements and sudden changes of direction.

Control the speed of the wheelchair when going down ramps.

Point to remember

• Do not move wheelchair without informing student, either verbally or using visual cues.

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8. Student is fearful when being transferred in hoist

Students with physical disabilities who require a hoist for transfers may experience feelings of movement sensitivity and gravitational insecurity. If the hoist is essential for transfers, this is unavoidable, but some strategies may reduce the student’s anxiety with movement.

Suggested strategies:

• Always prepare the student for the movement. Use a visual system to show what is going to happen and use this each time.
• Give the student time to calm before the movement.
• Stop the movement of the hoist if requested by the student if it is safe to do so. The student can be given a ‘Stop’ card to hold up if feeling anxious. Begin the movement again when the student is calm and ready.
• Teach the student calming strategies which may reduce anxiety during the movement in the hoist. Examples may include:
  • Breathing exercises e.g. deep breaths in and breathing out slowly
  • Holding a favourite item as a distractor/calming object
  • Focusing on a static point during the movement
• A weighted lap cushion may help to reduce feelings of movement sensitivity. Consult with an occupational therapist before using a weighted item.
• Give the student time to use calming strategies after the transfer in the hoist is complete:
  • Breathing exercises e.g. deep breaths in and breathing out slowly
  • Deep pressure exercises e.g. hand pushes

Carrying out a preferred activity e.g. watching a favourite clip on the iPad

Point to remember

• Use a visual system to show student how he/she will be lifted in hoist and where he/she is being moved to.

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