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WHY IS SI CRITICISED FOR HAVING NO EVIDENCE? 

If you explore the evidence base for SI. There are numerous studies relating to the neuroscience behind sensory integration. There is a wealth of research which is highly scientific and backs up what is seen in practice. This is why Sensory difficulties are now included in the DSMV and the NICE guidance for ASD. Unfortunately, as with many of the interventions provided by therapists the evidence base in terms of intervention for these sensory difficulties is limited. This is not because the interventions don't work, but rather due to the challenges which are integral to conducting research with human subjects. 

The challenges to conducting research in SI are considered below:

  • No definite diagnosis has been confirmed, therefore research papers use different terms and definitions. If a study uses a measure of sensory responsivity such as the Sensory profile it can only report on this not sensory integration in its totality. More studies are needed to define diagnostic clusters and also the tools used to identify the clusters. The DSM has requested more evidence for this to be a differential diagnosis rather than a associated symptom of another diagnosis such as ASD. There are studies emerging which are showing differences in the white matter microstructure in the brains of individuals with Sensory Integration Difficulties and those without.
  • Studies use varied measures to identify sensory problems, this leads to difficulties with replicating the research and also ensuring each research study is referring to the same thing. Some measure of Sensory integration have been validated using objective physiological measures such as Salivary cortisol levels, Electro Dermal Responses and Vagal Tone.
  • Sample groups are often small or single subject studies conducted, considered lower down on the research hierarchy. If we are to recruit larger sample groups we need to aim towards an homogeneous group. This is challenging as individuals with sensory difficulties often have more than one diagnosis, they have complex social economic and family backgrounds which impact on their occupational performance and participation difficulties. It is impossible to have a sample group that are identical due to the unique nature of humans. Age, diagnosis, background, presenting difficulties etc.
  • Defining the intervention, prior to the fidelity measure being available was tricky as no clear guidance was available for defining what Ayres SI therapy is. This was open to interpretation and clinicians were claiming they were using this intervention but when analysing their interventions we find that they were not using true SI therapy/intervention
  • Training, experience and knowledge of the clinicians providing the therapy needs to be clear. The Ayres 2020 vision is working on developing a standard for SI training as there are inconsistencies. The fidelity measure also outlines the level of post graduate training required. Research prior to this tool being developed again was limited by the inconsistent skills and training of the clinician.
  • Ethics plays a big part in research, when providing therapy as part of research in order attribute the outcomes to SI it may require the person to stop any other interventions. This presents with ethical challenges. Randomised control trials are deemed to be the gold standard studies which create barriers in regards to ethics. Giving intervention to one group and not to the other is unethical and difficult to justify.
  • Funding In the UK is limited for health research unlike the USA. Therefore many of the studies are coming from the USA. This makes it difficult to translate the findings to a UK population.
  • Outcomes and aims of therapy for Ayres SI is to give rise to more effective and efficient adaptive responses. However, this has to be linked to occupational performance and participation. For individuals the functional outcomes can be difficult to measure. Some measures are not sufficiently sensitive to measure changes, particularly measures of sensory integration. Many of the measures were not designed to be used as outcome measures due to this lack of sensitivity. Varied outcome measures are used across studies. In addition, the outcome measures used do not highlight the incidental changes made such as emotional well-being, family/caregiver stress and quality of life.
  • Efficacy, appropriateness and feasibility is required in relation to interventions. Reporting on the efficacy of an intervention you would ask, does it work as intended? Does it give rise to changes in the CNS and adaptive responses. However, there also needs to consideration as to how appropriate it is, will it impact on the family? Will it be done and is it acceptable to the family? Do they see the outcomes as beneficial. In addition to this feasibility, can it be done as it was intended, does it have impact on the provider,are their resources available? In clinical practice the effectiveness, appropriateness and feasibility will be required for an intervention to be fully evaluated and evidenced as all factors can have an impact on the success of the intervention. It also means that however effective an intervention is, if it can’t be adequately implemented or is unacceptable to the consumer it’s value is questionable. Studies which address appropriateness and feasibility are often regarded as providing lower level evidence but they provide legitimate contribution to research in healthcare.
  • Critiquing the critics, SI therapy has been criticised for being no more effective than other interventions for children with ASD (Lang, 2012). However, Jane Case Smith (2014) in her systematic review has provided a more comprehensive exploration and critique of the existing research. Her synthesis of the research evidence suggests that the SI approach may result in positive outcomes in the areas of sensori-motor skills and motor planning, socialisation, attention, behavioural regulation, reading and reading related skills. SI has shown to have better outcomes than those associated with the no treatment groups in many studies and was just as effective than alternative treatments such as perceptual motor and tutoring/academic based (May Benson & Koomar 2010 and Pfeiffer, 2011). To note an intervention that is ‘as effective’ as other interventions does not mean it is ineffective. Other examples of intervention studies for sensory difficulties such as those relating to sensorimotor interventions have similar methodological flaws such as varied research designs and outcome measures therefore limiting the generalisation of the findings. All studies examined in Polatajko & Cantin’s (2010) review highlighted the need for well-designed studies exploring the efficacy of well-defined interventions with homogeneous populations, in order to link specific outcomes to specific interventions. The evidence base for SI is addressing these recommendations in the most recent research and demonstrating positive outcomes.

What are we doing about it?

  • New research such as Schaaf’s (2013) RCT has addressed many of the limitations previously acknowledged in the research methodology in SI. The study shows high rigor in its measurement of the treatment fidelity and use of a manualised protocol. Goal Attainment Scale was able to capture change in function/participation that may be linked to changes in sensory integration as a result of the intervention. This study supports more recent thinking that short bursts with high intensity (2 to 3 sessions/ week for 6-10 weeks) can provide significant results. The children receiving ASI scored significantly better on measures of caregiver assistance in self-care (p=.008,d=0.9) and socialisation (p=.04, d=0.7).
  • Manualised Ayres SI, with the publication of the manualised SI therapy for children with ASD which includes driven decision making to guide clinical reasoning as well as the fidelity measures there are great advances being made in the clinical delivery of SI which will inevitably constituent to the rigour of the research.
  • National Institute for Health Research (NIHR) has acknowledged that the impact of ASD on public health and the economy is so significant that more research is needed to evidence the efficacy of interventions for this population. The call for an RCT in the NHS for SI with children with ASD is a massive step in being able to develop the evidence base for SI.

For more information on how to search and critique the research please refer to SensorNet issue 38

To understand the difference between clinical audit, service evaluations and research studies please refer to SensorNet issue 36

All SensorNet issues have research updates to keep you up to date with new and emerging research.


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