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COPYRIGHT NOTICE
BFDEI/-(8&/'5)'&)(4)%,
All rights reserved.
A Taste of TMR Tots for Torticollis No part of this program may be reproduced or transmitted in any form or
by any mean without the written permission of the publisher.
developed by Susan M. Blum PT
Intro to file links / manual Evidence based medicine is the conscientious, explicit, and
Need Now: judicious use of current best evidence in making decisions
about the care of individual patients. The practice of evidence
A. (tort) Releases & Worksheets, Agenda, &
based medicine means integrating individual clinical expertise
Post Course Instruction & Evals
with the best available external clinical evidence from
systematic research. By individual clinical expertise we
Need Post Seminar:
B. Blank Forms - duplicatable for clients mean the proficiency and judgment that individual
clinicians acquire through clinical experience and clinical
practice. Increased expertise is reflected in many ways,
C. Parent Handouts - duplicatable for clients
but especially in more effective and efficient diagnosis and
Optional Reference: in the more thoughtful identification and compassionate
D. (tort) PowerPoint pdf for your review use of individual patients predicaments, rights, and
preferences in making clinical decisions about their care.
E. Bibliography (Sackett et al 1996)
KEY SLIDES
8 years of Tots
> 600 Therapists Implementing Concept reporting and
demonstrating consistent
Osteopathic Approach
Treatment Order for Homeostasis
Lauren Noto-Belle, DO
TMR
Concept
TMR
Concept
The FOCUS Factor - The Shift
TMR does not replace what you do
1. Our perspective
2. Our care plan
3. Parents understanding & implementation The concept is a FILTER to help you
4. Childs control figure out how to get the best results
5. Our long term expectations
PERSPECTIVE SHIFT We ask what is pulling him to left?
Teaching Listening
Instead of asking: Listening with eyes and hands
Testing
g: [Teest Lefft vs Rightt forr Asym
mmetries] [You caannot have the sam
me # morre than onc
ce]
"%&,&' '7"7>!'#%"&&
"!!'"!*'(!'"!7)"# !'&&(&
A. UPPER TW
WIST B. SIDE BE
END
D C. LE
EG RA
AISE D. ARM RA
AISE E. LOWER TW
WIS
ST F. LEG DA
ANG
GLE G. STAND
D to SIT H.. ARM PRES
SS
Hard TMR # Rank Hard TMR R# Rank Hard T
TMR # Rank Hard TMR # Rank Hard TMR # ank Ha
Ra ard TMR # Rank Harrd TMR R# Rank Hard TMR R# Rank
Side [1-100
0] Side [1-10
00] Side [[1-100] Side [1-100
0] Side [1-100] Sid
de [1-100
0] Sid
de [1-10
00] Side [1-10
00]
Imp
pairm
men
nt (B
Bod
dy Struc
ctu
ure and
d Functtio
on)
!" #'%&('&
Cha
ange in
n Impairrment Hom
me Progrram Des
scription
n of Po
osition/ Mottio
on Th
herap
peutic
c Play - Ea
asy Side
e
2nd
d Exercise Hard Side = TMR # What did you do
o/ho
ow ma
any/ho
ow long? TM
MR # What did you do/how
w man
ny/h
how
w long? MR # What did you do
TM o/how
w man
ny/how
w long? TMR #
Cha
ange in
n Im
mpaiirm
men
nt Hom
me Progrram Des
scription
n of Po
osition/ Mottio
on Th
herap
peutic
c Play - Ea
asy Side
e
!%&'!"*'" #"*% &'" !!
(!'",%"('!&
3rd
d Exerrciise Hard Side = TMR # What did you do
o/ho
ow ma
any/ho
ow long? TM
MR # What did you do/how
w man
ny/h
how
w long? MR # What did you do
TM o/how
w man
ny/how
w long? TMR #
Cha
ange In
n Impairrmen
nt Hom
me Progrram Des
scription
n of Po
osition/ Mottio
on The
erapeutic Pllay
y - Easy Side
Cha
ange in
n Ac
ctivitty Lim
mittation
n
Sig
gnature & Plan
#%")0
( %!%"&'%'"!&+#!*,&" "*"&#%""!&'%'!8&%&'!9%
&'"!%"% ')!" #'%&('& %" $(&'%''"&'%"&3
"!&%'"!!'"!'*! Tape
p Placement for Doll - What will be Developmental Issues?
",'%('(%!(!'"!"!)"# !'
)1)-,-.,#.#)(#'*./((3;
)1)."3&#'#.#&#.3.)0&)*-.,(!."(
').),)(.,)&;
".'#&-.)(-&#'#.;
"..#0#.#-&#'#.;
)1'#!".&#'#(.#(!."-,-.,#.#)(-
,-( ),-,0#-5-/**),.-;
TMR Patient Functional Profile TMR Patient Functional Profile
Patient Name: DOB: Patient Name: DOB:
Date: Therapist signature: Date: Therapist signature:
3) Activity (Limitation): Not yet able to: 3) Activity (Limitation): Not yet able to:
1. 1.
Sit up tall
2. 2.
Pull to stand
Zoom Out 3.
4.
What cannot yet do?
3.
4.
5.
6.
5.
6.
Hold spoon
7.
8.
7.
8. Vocalize loudly
Catch ball
9. 9.
10. 10.
4) Impairment:
Impairment: Wha
Whatt - Where
Where - How 4) Impai
Impairment:
rment: Wha
Whatt - Where
Where - How
Hard
Side
TMR #
[1-100
0]
Rank Hard
Side
T
TMR #
1-100
[1 0]
Rank Hard
Side
T
TMR
[1
#
1-100]
Rank Hard
Side
TMR #
[1-100
0]
Rank Hard
Side
TMR #
[1-100]
Rank Ha
ard
Siide
TMR #
[1-100
0]
d
Rank Hard
Side
TMR R#
[1-10
00]
Rank Hard
Side
TMR #
[1-100
0]
Rank Body weight displacements, body sensations of loading
Imp
pairme
ent (Bo
ody Sttruc
cture and Functio
on)
pressure changes, and resulting muscle activations for righting
Describe Where does Tape Begin and End? Restriction Left Armpit to Hip
the head and body are faulty. The necessity for maintaining
Tre
eatmen
nt: [F
[From
1stt Exerrcis
se
m Here
e Out - Co
omp
Hard Side
pare Hard
=
d Sid
de Onlyy to
o Itsself Not to Th
he Ea
MR # What did you do//how maany/ho
TM
asy Side]
ow long? TM
MR # What did you do/h
how ma
any
y/ho
ow long? TM
MR # Whatt did you
u do/h
how ma
any/ho
ow long? TMR #
upright posture is then evident in the compensatory use of the
limbs, rather than the neck, trunk, and hips
Imp
pairme
ent (Boody Sttruc
cture Hom
me Progrram Desc
cription
n off Pos
sition
n/ Treatm
ment Hom
me Pro
ogra
am Thera
apeutiic Play
d Func
and on)
ctio
Cusick, 2012
2nd
d Exerrcise Hard Side = TM
MR # TM
MR # MR # Whatt did you
TM u do/h
how ma
any/ho
ow long? TMR #
Cha
ange in imp
pairm
ment Hom
me Progrram - Desc
cription of Mo
otion Hom
me Pro
ogra
am Func
ction or Pla
ay
Visit 1
Visit 2
Can actively rotate to left side, but restricted to right Can actively shorten left side, but restricted to right
Same restrictions cause sit on right buttock
Rotation improves very slowly - Partially retightened stabilizing for
Limit wt shift & protective reaction to left & play to right side
new motor milestones and when immobilized when ill
VITAL NOTE:
My videos show fast motion ( This is because I
already know the end range as have worked with
these children. )
We test and treat slowly and gently
"* '%&'%'"!&)"#3
'')#.#)(@1)'"/&.4@EMMJA6
(*,)&)(!
&#'#..#)(-#(*)-#.#)(#(!)*.#)(-/.)#&&(--61%(--6
"3*).)(#6)(.#(,%#-6.AO)'*(-.),3*.#0
"),.(#(!
'#-/-6)0,/-6#-/-6#--(.,/'
During expulsion in LOA presentation the pressure of the The Man in the Suit
mothers sacrum may result in frontal flattening on the left and the &
pubic symphysis may flatten the right occiput
Compensatory Adaptive Shortening
Somatic dysfunction should be sought out and treated as soon as
possible to avoid any dysfunctional sensorimotor integration What if you stayed that way for a week? a month?
during the early developmental periods in order for the infant to a year?!?
develop the best head and trunk postural control and mechanics. How would your function be impacted?
Where would you develop hyper mobility or pain?
Crawling delays and transition in and out of sitting are associated ____
with somatic dysfunction in the pelvis needed to develop the
sensory system and motor skills. What is tight stays tight!
_ (Sergueff, Nicette 2007 p. 12-13, 37-38) Consider long term positioning on our Container Kids!
GO SIDE GO SIDE
8 4
7 5
Pre6Tx Post
Just where is it the tightest as you move your hand and explore
tissues? Where does it hit a block or feel gummy? If we can identify the angle of the line of pull of red tape
Explore texture keeping hands soft we can be more precise with release
(Like wiggling your hair and scalp without pushing on skull) Just where is it the tightest and at what angle?
Place release hand in position that mirrors test hand
Test Tx
Test Tx
Imp
pairm
men
nt (B
Bod
dy Struc
ctu
ure and
d Functtio
on) Ask Yourself - Importance of clinical observation on
What are components LIMITING above activity ? EG: range
(Describe origin and insertion of bungee cord or tape)
function = time well spent.
Tre
eatm
ment: [Froom Heere Outt - Com
mparre Harrd Siide Onlyy to Itsself Not to Th
he Easy Side]]
1stt Exerrcise =
Hard Side TMR # What did you do
o/ho
ow ma
any/ho
ow long? TM
MR # What did you do/how
w man
ny/h
how
w long? MR # What did you do
TM o/how
w man
ny/how
w long? TM
What does their body want to do?
Cha
ange in
n Impairrment Hom
me Progrram Des
scription
n of Po
osition/ Mottio
on Th
herap
peutic
c Play - Ea
asy Side
e
Identify and describe restrictions as precisely as
possible on the form
2nd
d Exercise Hard Side = TMR # What did you do
o/ho
ow ma
any/ho
ow long? TM
MR # What did you do/how
w man
ny/h
how
w long? MR # What did you do
TM o/how
w man
ny/how
w long? TM
DEMO: Parent Concern/ Issue: Cant pull to stand with left LE "*"&%&'%'"!3
LAB: View video, then repeat trying restriction on self
%&'#3
0
#/&&.).(9&&3.)#!".@#!".
)1,
1#-.A
,'3,1&
E=F(&
,/#-
")/&,P&2#)(
TMR Terminology
Hard vs Easy Side TMR Terminology
WHAT IS THE DIRECTION OF EASE?
We look at motions in terms of ability to actively shorten through Shorten a necklace to get rid of Knot
the range. What is the CRUNCH SIDE?
How would you position yourself get cozy on a pillow? - Curl up to
If I try to move deeper into the barrier of the hard side the tissues fit into a box?
may feel thick, gummy, and if I push further it may cause pain when I
hit a block. . The direction of ease shortens the restrictions (like releasing
bungee cords) and is the direction of comfortable
If I try to move deeper to the easy side, hold it a while, breathe,
possibly jiggle, the tissues slowly elongate and feel fluid like silly
putty allowing me to go deeper and deeper without discomfort as
long as I dont go too fast, too hard or stretch.
How is Activity (sitting) limited?
Where is the Restriction?
What is her hard side for side bend & rotation?
Red is Tape- Green is Silly Putty
"*! #%") "',!"!% #%")")% Muscles in line are like 2 springs connected in series
&'%('(%!3 (eg: back and hips)
3*)')#&.3#(.,)((.-.")/!")/.)39*,)2#'&
.)#-.&6#-.&.)*,)2#'&6-'-#6)**)-#.-#6.)*=
)..)'6)..)'6=.)*(#!)(&-
* The more extensible one takes up the slack
,.-"3*,')#&#.3("3*)')#&#.3#'&(-
and can become hypermobile
* & symptomatic
&-1",8>
'*,)0')#&#.3#()(,"-"#(
,.#)(#(.)).",-8
The key is treat the hypomobile one first
(The place that hurts may not be the problem)
IMMOBILIZATION CASCADE
'&'&!. "*&& %'"
Hypomobility effects Developmental Sequence "&'"!&"%'%!"(!'%'%!3
"),.(.#--/.)&(!."((#'*,)0,(!
Hypermobility Elsewhere in Body (&."#(! .
Fascial Bias
How Restrictions Might Be Treated Indirectly
THERAPEUTIC POSITIONING and TMR RELEASES -
Moving into the Direction of Ease
The side that the Silly Putty elongates to go deeper over time
Royder, Structural influences in temporomandibular joint pain and dysfunction, JAOA, 1981
Need elongation of anterior for ACCESS to
Evidence Supporting the Perimyseal Plasticity fully contract of deep postural muscles
Hypothesis described by Cusick 2013
Traditional PT Traditional PT
TMR TMR TMR TMR TMR TMR
Prep Phase Enhanced Traditional Dynamic Phase Prep Phase Enhanced Traditional Dynamic Phase
"*!*!#%">!,!'%'!!
&'!!'"#'!'4&",3
? ,(&*.#)((&-
?)."(!#(,,#,( /(.#)(8
What is Contralateral Lengthening?
Lets Try an Example of TMR on Ourselves
LAB: Upper Twist
(.,.'(.-".1#."-,#*.#)() ').#)(-A
ED
BREATHE!
Everything is connected "*!*%!'"%&'%'"!"!&!3
Closing posture - Exhale - Note how you can do -.)(-& ."# ,(.1(3)/,F-#-
Kegels as belly button touches spine and sit bones ),"').#)(
come together
'.'""%3
Opening posture - Inhale - Note how pelvic floor '%'"!& %)&.&,3
relaxes and softens with expansion of abdomen so
that sit bones separate. @#!".0-8
.A
EG: Trunk flexion & Stand to sit are closing postures "*)%3
Twist to side & Arm raise are opening postures
@#!=#/'='&&O=&&)1=,(A
When we treat we cue the client to BREATHE
How Severe is Restriction?
Red Light Green Light
What Color?
High %
Assessment of color should be reliable
Severe Large RED
between 2 therapists or caregivers
as only 3 choices:
Medium
Big Medium Small
Moderate Medium YELLOW
Copyright 2011 Total Motion Physical Therapy Total Motion Release and TMR are trademarked by Thomas Dalonzo-Baker
"*!*%!'"%&'%'"!"!#%'!%!
3
What if there is an issue but little difference?
(IE: Bilateral hamstrings in diplegia) -.)()&&1#."*5,.(,-."# ,(
Little right vs left difference is green .1(."#,F-#-
Not choice for treatment
Still concern so will recheck at end of session '.'""%3
Mark with a ! '%'"!& %)&.&,3
Melding with the patient like holding Silly Putty Our hands just go along for the ride and listen
Honor him - dont make a choice for him
We may offer support so they can relax & discover how much
they can move in a range that they may have been splinting over
protectively
Honor Them
Its not about us - Be sure we arent trying to prove we are doing something
Copyright 2011 Total Motion Physical Therapy Total Motion Release and TMR are trademarked by Thomas Dalonzo-Baker
Dalonzo Baker 53
Discuss:
Why range of Upper Twist so vitally important for all How would you caress a Balloon in both hands to twist?
How would you feel Big Hair?
systems in body?
Try UT TREATMENT -
Release on Partner (90-120 sec) "*"*'%'&3
Signs of Release
*-) F'#(2F>-.(,8
Softening of tissue .-.CF ),.,.#(!
Lengthening - means you are into collagen
Increase flow of fluid, energy, heat,
Client may breathe deeper or have physiological "*"*'%'3
changes
Relaxation of increased tissue tone *-) F'#(2F>-.(,8)/'(.).",
@*.)(")/,,&-*)--#&A
.-..#(.,0&-),.() ').#)(
.31#."').#)(/(&--,-)(.)"(!
.-.CF ),.,.#(!
UT in Fragile Child - Follow along with Doll
Try UT on Doll
How lightly can you hold doll?
>80%
Young Children
have a
Sternum Upper Twist left
and
Lower Twist right
Belly Button The Sternum Rules!
Lower Twist is the Direction
Always confirm Visual with Touch ! Belly Button is Turning (not about LEs)
).7"#-1#&&)0,.() ---#)(
Ranking
Sequence To Straighten the Blanket
Testing
g: [Teest Lefft vs Rightt forr Asym
mmetries] [You caannot have the sam
me # morre than onc
ce]
The 8 motions are the Basics we must check
(Includes 9th motion demanding attention which override
may the others for rank)
A. UPPER TW
WIST B. SIDE BE
END
D C. LE
EG RA
AISE D. ARM RA
AISE E. LOWER TW
WIS
ST F. LEG DA
ANG
GLE G. STAND
D to SIT H.. ARM PRES
SS
Hard
Side
TMR #
[1-100
0]
Rank Hard
Side
TMR R#
[1-10
00]
Rank Hard
Side
T
TMR #
[[1-100]
Rank Hard
Side
TMR #
[1-100
0]
Rank Hard
Side
TMR #
[1-100]
Ra ard
ank Ha
Sid
de
TMR #
[1-100
0]
Rank Harrd
Sid
de
TMR R#
[1-10
00]
Rank Hard
Side
TMR R#
[1-10
00]
Rank The 4 Core motions (Twists, Side Bends, Leg Dangle) are
foundational
Imp
pairm
men
nt (B
Bod
dy Struc
ctu
ure and
d Functtio
on)
We can manage with a limited arm raise or leg raise,
but
Tre
eatm
ment: [Froom Heere Outt - Com
mparre Harrd Siide Onlyy to Itsself Not to Th
he Easy Side]]
1stt Exerrcise Hard Side = TMR # What did you do
o/ho
ow ma
any/ho
ow long? TM
MR # What did you do/how
w man
ny/h
how
w long? MR # What did you do
TM o/how
w man
ny/how
w long? TMR #
Red twist or side bend makes us too off balance to work on
function when patient has not had previous motor control
Cha
ange in
n Impairrment Hom
me Progrram Des
scription
n of Po
osition/ Mottio
on Th
herap
peutic
c Play - Ea
asy Side
e
2nd
d Exercise Hard Side = TMR # What did you do
o/ho
ow ma
any/ho
ow long? TM
MR # What did you do/how
w man
ny/h
how
w long? MR # What did you do
TM o/how
w man
ny/how
w long? TMR #
LAB:
Demo all 6 motions on a volunteer while class tries them all
on themselves and completes a form and then treats their
top 1 or 2 motions
Tots 2
S curves are TMR 2 level treatment
Top Down
Tots 2 B1 B2 Top
#.Top Down SB#. Bottom Up SB*. Flex/Extend +,. Bent Knee Toe -. Hip Shift .. Leg Lift Back Down
Hard TMR # Rank Hard TMR # Rank Hard TMR # Rank Hard TMR # Rank Hard TMR # Rank Hard TMR # Rank Hard TMR # Rank Hard TMR # Rank
Side (1100) Side (1100) Side (1100) Side (1100) Side (1100) Side (1100) Side (1100) Side (1100) Bottom S
Up
Treatment: From here out, COMPARE HARD SIDE ONLY TO ITSELF, not to Easy Side. [All exercise is to EASY SIDE.] A. UPPER TW
WIST B. SIDE BE
END
D C. LE
EG RA
AISE D. ARM RA
AISE E. LOWER TW
WIS
ST F. LEG DA
ANG
GLE
Hard TMR # TMR # Easy Hard TMR #
1st Exercise Side (1100)
What did you do? How many? How Long? (1100) Side
Home Program (Position Treat Play) Rank Hard TMR R# Rank Hard T
TMR # Rank Hard TMR # Rank Hard TMR # ank Ha
Ra ard TMR # Rank
Side [1-100
0] Side [1-10
00] Side [
[1-100] Side [1-100
0] Side [1-100] Sid
de [1-100
0]
R Med 4
L Big 1
Imp
pairm
men
nt (B
Bod
dy Strucctu
ure and
d Functtio
on)
Hard TMR # TMR # Easy
Moderate limitation of elongation left ribs to drop right armpit
2nd Exercise Side (1100)
What did you do? How many? How Long? (1100) Side
Home Program (Position Treat Play)
SEVERE limitation of elongation on right side between ribs & pelvis to elevate left hip
Tre
eatm
ment: [Froom Heere Outt - Com
mparre Harrd Siide Onlyy to Itsself Not to Th
he Easy Side]]
3rd Exercise Hard TMR # TMR #
What did you do? How many? How Long? (1100) Easy Home Program (Position Treat Play)
1stt Exerrcise Hard Side = TMR # What did you do
o/ho
ow ma
any/ho
ow long? TM
MR # What did you do/how
w man
ny/h
how
w long? MR # Wh
TM
Side (1100) Side
Tes
sting
g: FAB
B 8 [T
Testt Left vs Right forr Asy
ymm
metrie
es] [You
u cannot have the same
e # mo
ore than
n onc
ce]
G.-S
STAND
Standing
D to SIT H. ARM PR
RESS
Hard TMR # Rank Hard T
TMR # Rank Hard T
TMR # Rank Hard TMR # Rank Hard TMR # Rank Ha
ard TMR # Rank Hard
d TMR R# Rank Hard TMR # Rank
Side [1-100
0] Side 1-100
[1 0] Side [1
1-100] Side [1-100
0] Side [1-100] Siide [1-100
0] Side [1-10
00] Side [1-100
0]
bac
Tre
uts) to liftt selff up ste
(glu
inch
hes froomm floo
ep - Has
or/ riigh
ck at riibss to rright sid
eatmen nt: [F
[From
de bel
m Here
H right
ht 4 inc
r t fo
b low waisst
e Out - Coomp
oot tuurrned
pare Hard
d outt 20 de
acrral sittss) Pe
inchess - sa
d Sid
egrrees > le
elviss doess no
de Onlyy to
ot roo
otate
eft ( B
Bilate
e to left. P
o Itsself Not to Th
*
erall hamsstri
Pullss acr
he Ea
a ross lo
asy Side]
ow
ring c
w bacc
connttractu
on diag
ck on
uress - Le
gon
eft h
heel 7
nal frrom mid
m
1stt Exerrcis
se Hard Side = MR # What did you do//how maany/ho
TM ow long? TM
MR # What did you do/h
how ma
any
y/ho
ow long? TM
MR # Whatt did you
u do/h
how ma
any/ho
ow long? TMR #
R - 2 min x 2 on
n bac
ck 5 min
m overre
e h leftt
each child
d tire
ed - cha
ange
Lo
ower Twist L = Big
80 50
Big foott to rightt side
e
40
Med
moottion --
Cha ange in
i Imp pairmmen ntIP
P lls
Pul me Prog
Hom grram Desc
D criptio
on of
o Positi
o on/ Motiio on T
The
erapeu
utic
c Play
y - Easy
E Side
e
lesss -moree fllexible accrosss lo
ow REL ASE: - On back- su
LEA uppportt leftt buttoc
ckk THE
T ERAPEEUT P Y: Sam
TIC PLAY me mottion havee
back to ro
otatte be
elly bu on tto
utto o le
eft (backk pocckket - not thigh) to help
h child chilld acttive
c ely seg
s gmmentally y rolll to right to
to
crosss left leg acro
a oss bo ody
y annd
n go deepe er ove
e o erreac ch with h fo
ooot to
o tou
uch targ get witth
h
o motio
into m on n2m min x 3 (4 5 tim
4-5 mes
m a day EG: leeft foot (leet up
p err bod
ppe dy pass
p sively follo oww)
at dia
d aper cchan nge)
2nd
d Exerrcise Hard Side = MR # What did you do//how maany/ho
TM ow long? TM
MR # What did you do/h
how ma
any
y/ho
ow long? TM
MR # Whatt did you
u do/h
how ma
any/ho
ow long? TMR #
S
Side Be
end L - 3 min
m - bring
b g leftt hip addle bo
Stra olster and
a d Tiltt in sp
pace
e cru
unch all
R 60 45 35 30
m up)
(bottom bottom o
to b of rib ge
b cag e L hip - ribs
hike r s stra
s aight moottion b ow ribs
belo
Parrent/P
Patien
nt Con
nce
ern
n Actiiviity Limitation
n
Testing
g: [Teest Lefft vs Rightt forr Asym
mmetries] [You caannot have the sam
me # morre than onc
ce]
LAB:
A. UPPER TW
WIST B. SIDE BE
END
D C. LE
EG RA
AISE D. ARM RA
AISE E. LOWER TW
WIS
ST F. LEG DA
ANG
GLE G. STAND
D to SIT H.. ARM PRES
SS
Imp
pairm
men
nt (B
Bod
dy Struc
ctu
ure and
d Functtio
on) May add other motions of ease to go deeper into motion
EG: side bend
Tre
eatm
ment: [Froom Heere Outt - Com
mparre Harrd Siide Onlyy to Itsself Not to Th
he Easy Side]] May move extremities as you let go
1stt Exerrcise Hard Side = TMR # What did you do
o/ho
ow ma
any/ho
ow long? TM
MR # What did you do/how
w man
ny/h
how
w long? MR # What did you do
TM o/how
w man
ny/how
w long? TMR #
Cha
ange in
n Impairrment Hom
me Progrram Des
scription
n of Po
osition/ Mottio
on Th
herap
peutic
c Play - Ea
asy Side
e
DO NOT OVER DO!!!!
Weight Bearing 2 used to Organize infants post
release treatment (Later used to treat restrictions)
2nd
d Exercise Hard Side = TMR # What did you do
o/ho
ow ma
any/ho
ow long? TM
MR # What did you do/how
w man
ny/h
how
w long? MR # What did you do
TM o/how
w man
ny/how
w long? TMR #
Cha
ange in
n Im
mpaiirm
men
nt Hom
me Progrram Des
scription
n of Po
osition/ Mottio
on Th
herap
peutic
c Play - Ea
asy Side
e
Parrent/P
Patien
nt Con
nce
ern
n Actiiviity Limitation
n
Testing
g: [Teest Lefft vs Rightt forr Asym
mmetries] [You caannot have the sam
me # morre than onc
ce]
Rule 1
If it's ge
g ttingg better stayy on the same track.
A. UPPER TW
WIST B. SIDE BE
END
D C. LE
EG RA
AISE D. ARM RA
AISE E. LOWER TW
WIS
ST F. LEG DA
ANG
GLE G. STAND
D to SIT H.. ARM PRES
SS
Keep on Keeping ON
Hard TMR # Rank Hard TMR R# Rank Hard T
TMR # Rank Hard TMR # Rank Hard TMR # ard
ank Ha TMR # Harrd TMR R# Rank Hard TMR R#
Side [1-100
0] Side [1-10
00] Side [1-100]
[ Side [1-100
0] Side [1-100]
Ra
Sid
de [1-100
0]
Rank
Sid
de [1-10
00] Side [1-10
00]
Rank
Dont change motion unless you hit a roadblock!
Imp
pairm
men
nt (B
Bod
dy Struc
ctu
ure and
d Functtio
on)
Rule 2
Tre
eatm
ment: [Froom Heere Outt - Com
mparre Harrd Siide Onlyy to Itsself Not to Th
he Easy Side]]
1stt Exerrcise Hard Side = TMR # What did you do
o/ho
ow ma
any/ho
ow long? TM
MR # What did you do/how
w man
ny/h
how
w long? MR # What did you do
TM o/how
w man
ny/how
w long? TMR # If your
y going
g g to slow - Speed
p Up.
p
Cha
ange in
n Impairrment Hom
me Progrram Des
scription
n of Po
osition/ Mottio
on Th
herap
peutic
c Play - Ea
asy Side
e
Rule 3
If yyou are ggoing the wrongg wayy
2nd
d Exercise Hard Side = TMR # What did you do
o/ho
ow ma
any/ho
ow long? TM
MR # What did you do/how
w man
ny/h
how
w long? MR # What did you do
TM o/how
w man
ny/how
w long? TMR #
turn around and ggo the other way. y
Cha
ange in
n Im
mpaiirm
men
nt Hom
me Progrram Des
scription
n of Po
osition/ Mottio
on Th
herap
peutic
c Play - Ea
asy Side
e
Copyright 2011 Total Motion Physical Therapy Total Motion Release and TMR are trademarked by Thomas Dalonzo-Baker
37
LAB: Treating your self - Motion #1
Treating:
Start with Progress to DYNAMITE
TWEEZERS
Options
Tweaks to Accelerate Change
y Increase Intensity (Lower chair - Deeper Range)
')%&!*(&'"!!' "'"!3
y Increase Duration (2-3-5 Minutes)
#!!&6/,.#)(6-*6#(.(-#.36)')-
y Increase Number of repetitions
y Decrease Speed
y Zero in on a focused piece of the motion (chunking)
y Add soft tissue work in same direction
LAB
Post Treatment - Retest functional activity limitation:
Ability drive toy car side sitting on easy side
What is Jiggle vs Prolonged 1. How has your midrange changed post?
Release ? 2.
3.
What changes have occurred in your body
What is effect on your balance and equilibrium?
4. How easy is it to breathe, raise arms on hard side?
5. Is you ability to side sit to the hard side any different?
If something is crooked
'%)! "%#"&& "'"!&'" Make it more crooked
!',%&'%'"!&
#(!-5)1-.,#(!->)-,0-0,
Looking for Hinges
*)-./,&-3''.,3 ),M."').#)( If a finger is flexed or forefoot adducted,
",#-.".*; we can flex or adduct it more to shorten
",#-&)."#(! )&#(!; it and locally release the tension
Copyright
C h 2011 TTotall M
Motion Ph
Physicall Th
Therapy TTotall M
Motion R
Release
l and
d TMR are trademarked
d k d bby Th
Thomas D
Dalonzo-Baker
l B k 6
Visible Restriction = The Hinge
Hypomobile Epicenter - Screams for attention
Common 9th Motion - Visible See to assess - touch to confirm - Feel to see if Real
Optional Motions (more day 2)
If you pretest and post test in test position and treat however
you listen to the child you will be on track to move into his
Total Direction of Ease
Just LISTEN to
where they want to hinge
to treat
Ask, Listen & Respond
Documentation / Visit Objectives
Nam
me DOB The
era
apis
st Da
ate
Parrent/P
Patien
nt Con
nce
ern
n Actiiviity Limitation
n
8 STEPS - Every Single Visit
1 Focus 2 Functional Issue
Testing
g: [Teest Lefft vs Rightt forr Asym
mmetries] [You caannot have the sam
me # morre than onc
ce] '&'&$(!"!'%)!'"!3
8 STEP
FORM 3 Assess
(.# 3*,(.)(,( /(.#)(&)(,(
%)((.#)(.1(&#'#..#)(-
A. UPPER TW
WIST B. SIDE BE
END
D C. LE
EG RA
AISE D. ARM RA
AISE E. LOWER TW
WIS
ST F. LEG DA
ANG
GLE G. STAND
D to SIT H.. ARM PRES
SS
Hard TMR # Hard TMR R# Hard T
TMR # Hard TMR # Hard TMR # ard
Ha TMR # Harrd TMR R# Hard TMR R#
Rank Rank Rank Rank Ra
ank Rank Rank Rank
Side [1-100
0] Side [1-10
00] Side [
[1-100] Side [1-100
0] Side [1-100] Sid
de [1-100
0] Sid
de [1-10
00] Side [1-10
00]
Imp
pairm
men
nt (B
Bod
dy Struc
ctu
ure and
d Functtio
on)
@,-.,#.#)(-A( /(.#)(>.-%(&3-#-
4 Evaluate limitation
Tre
eatm
ment: [Froom Heere Outt - Com
mparre Harrd Siide Onlyy to Itsself Not to Th
he Easy Side]]
)!#&-3-.'.)+/#%&3#(.# 3&#'#.
1stt Exerrcise =
,(!-#(%3,-Test 6
Hard Side TMR # What did you do
o/ho
ow ma
any/ho
ow long? TM
MR # What did you do/how
w man
ny/h
how
w long? MR # What did you do
TM o/how
w man
ny/how
w long? TMR #
5 Treat
Cha
ange in
n Impairrment Hom
me Progrram Des
scription
n of Po
osition/ Mottio
on
7 Activity change
LAB:Try
S
Self & Doll Functional Side Bend
Left SB
Position Release Play
For babies we organize with
HOLD for specific time FUNCTION (use it or lose it)
bounce on knee,
precise MOTION at end range bounce against chest walking,
joint compressions,
input into vertical tibia
Position on Tilt to Right Tilt Further
or humerus
Right Hip So Childs Side to Increase
Crunches to Left Work
To Stay Up
Copyright 2011 Total Motion Physical Therapy Total Motion Release and TMR are trademarked by Thomas Dalonzo-Baker
Testing/ Treating/ Teaching
9th Motion - (What is their body asking to do?)
Habilitation Rehabilitation
!"**'%!8 "'"!&;.<93 Test 6 (Ideal ) Test 8
or
or Functional Motion
Habilitation - when E9J3&&)19),&(P#,-. Core 4
.))(.,)&2.,'#.#- or
@3/-#(-/**),.*)-#.#)( ),*,)*,#)*.#0#(*/..) Whatever you can do! Treat 2 / Teach1or 2
.() ---#)(A Focus on Upper/ Middle & Lower Body
Treat 2 / Teach1
''"!9#-/--# ,(#().-E
Nam
me
Total Motion for Tots 8 Step Form
DOB The
era
apis
st Da
ate
LAB:
Parrent/P
Patien
nt Con
nce
ern
n Actiiviity Limitation
n
Try WB motions on self
Testing
g: [Teest Lefft vs Rightt forr Asym
mmetries] [You caannot have the sam
me # morre than onc
ce] & add results to your 8 Step Form
ORGANIZE
Change Variables
A. UPPER TW
WIST B. SIDE BE
END
D C. LE
EG RA
AISE D. ARM RA
AISE E. LOWER TW
WIS
ST F. LEG DA
ANG
GLE G. STAND
D to SIT H.. ARM PRES
SS
Speed/ Height On elbows/ On hands?
Hard TMR # Rank Hard TMR R# Rank Hard T
TMR # Rank Hard TMR # Rank Hard TMR # Ra ard
ank Ha TMR # Rank Harrd TMR R# Rank Hard TMR R# Rank
Side [1-100
0] Side [1-10
00] Side [[1-100] Side [1-100
0] Side [1-100] Sid
de [1-100
0] Sid
de [1-10
00] Side [1-10
00]
Imp
pairm
men
nt (B
Bod
dy Struc
ctu
ure and
d Functtio
on)
Experiment with breathing out slowly as you sit
Tre
eatm
ment: [Froom Heere Outt - Com
mparre Harrd Siide Onlyy to Itsself Not to Th
he Easy Side]]
Add challenge
1stt Exerrcise Hard Side = TMR # What did you do
o/ho
ow ma
any/ho
ow long? TM
MR # What did you do/how
w man
ny/h
how
w long? MR # What did you do
TM o/how
w man
ny/how
w long? TMR # 1st AP -
then Lateral
Cha
ange in
n Impairrment Hom
me Progrram Des
scription
n of Po
osition/ Mottio
on Th
herap
peutic
c Play - Ea
asy Side
e
then Diagonal
Child with limited endurance issue and very limited control - Modify Raise Surface to get Vertical Arms
by providing 95% support
Still vital to do age appropriate skill!
ORGANIZE with WB motions (skip video)
"* #"%'!'&#"&'!'%)!'"!%!-'"!
'"'''!*!"% 3 Organization
/,)*&-.##.3>-#.),&)-#.:
Organization
Organization
Time to regroup
Body awareness
Proprioception
Wt Bearing TMR
Heavy Work
Excitement - Fun
BOMBARD both sides with
Sensory Input
"* #"%'!'&!&"%,!#(''""'&&3
)1(1*,)0#;
".%#() -(-),3#(*/.)/,-)(."",-#
1"(1&)."-3.)."2.,';
)1(1) ,/.().#'*)-)**),./(#.#-.)
/-."",-# .,&)#(!."-3;
Foot asleep
Get grounded with
Exaggerate pressure
pressure into foot
to feel foot
VITAL CONCEPT
The Hard side is not ignored -it gets as much therapy as the Easy
side BUT different therapy
The BULK of the therapy is sensory input to feed what was lost by
limited access during previous immobilization. Includes tactile &
visual
The hard side is EXPOSED to the opportunity to move (Vital for brain
development!) BUT not with a demand that imposes overwhelming
effort that may cause a undesired responses elsewhere in the body.
The Hard side models after the easy side AFTER the desired task is
performed with effort for maximum recruitment EG: intense quad
Jello Jigglers Snow Angels on Rug sets on right to show left how to work.
Pressure into joints, Contact on all surfaces
hands/feet of extremities When tactile input is used during motion on the easy side, the same
input is offered to the hard side without the demand for effort. EG:
Arm Raise - Reach for the plush toy with the hand on the easy side -
Feel the plush toy in the hand on the hard side
)1#-@EDD=MD=LDA-#,.),),."(
@
,!N=
,!=
,!9A Range &
Moderate Medium YELLOW
)%(!#03)/,)1(,-.,#.#)((/', Partial Skill
Low %
Skill Minimal Small GREEN Goal
Copyright 2011 Total Motion Physical Therapy Total Motion Release and TMR are trademarked by Thomas Dalonzo-Baker
What if more than one motion is red? Now revisit your Upper Twist give it a TMR number for imbalance
How do we know which is the most out of
balance? High % 100
90
90 to 70 Severe 70
Medium % 60
TMR number similar to pain scale 0-10 but we use 0-100 60 to 40 Moderate 50
Low % 30
100 = no mobility on the hard side 0 = BALANCED 20
10
Goal is 0 issue = symmetr 0
Caregiver Form
Caregiver Form Daily Home Program Pick motions ranking 1 & 2
Advanced Motions Name: Therapist:
5FTUoThe Rest of the Body for Asymmetries Test Left vs Right [You cannot use the same # more than once.]
Date: to select best strategy
TMR To
ots HOM
ME PROGRAM
NAME: DATE:
Nam
me
Total Motion for Tots 8 Step Form
DOB The
era
apis
st Da
ate
3 Test
FAB 8
A. UPPER TWIST
HARD
SIDE
# RANK POST # EASY
SIDE
HOME PROGRAM [Therapeutic Position - Treatment - Play] -Easy Side
Nam
me
Parrent/P
Patien
nt Con
nce
ern
n
DOB
Actiiviity Limitation
n
The
era
apis
st Da
ate
Parrent/P
Patien
nt Con
nce
ern
n Actiiviity Limitation
n
2 Lt
Testing
g: [Teest Lefft vs Rightt forr Asym
mmetries] [You caannot have the sam
me # morre than onc
ce]
A. Upper Twist B. Side Bend C. Leg Raise D. Arm Raise E. Lower Twist )/HJ'DQJOHG. StandUP4JU
Hard TMR # Rank Hard TMR # Rank Hard TMR # Rank Hard TMR # Rank Hard TMR # Rank Hard TMR # Rank Hard TMR # Rank Hard TMR # Rank
Side (1100) Side (1100) Side (1100) Side (1100) Side (1100) Side (1100) Side (1100) Side (1100)
H. Arm Press Testing
g: [Teest Lefft vs Rightt forr Asym
mmetries] [You caannot have the sam
me # morre than onc
ce]
5 Treat
B. SIDE BEND
Imp
pairm
TMR #
[1-100
men
0]
nt (B
Bod
RankHard
Side
dy Struc
ctu
TMR R#
[1-10
ure and
00]
d Functtio
RankHard
on)
Side
T
TMR #
[[1-100]
RankHard
Side
TMR #
[1-100
0]
Rank Hard
Side
TMR #
[1-100]
Ra ard
ank Ha
Sid
de
TMR #
[1-100
0]
Rank Harrd
Sid
de
TMR R#
[1-10
00]
RankHard
Side
TMR R#
[1-10
00]
Rank
C. LEG RAISE
buttock and
Imp
pairm
men
nt (B
Bod
dy Struc
ctu
ure and
d Functtio
on)
#.Top Down SB#. Bottom Up SB*. Flex/Extend +,. Bent Knee Toe -. Hip Shift .. Leg Lift Back
Turn to left to
Tre
eatm
ment: [Froom Heere Outt - Com
mparre Harrd Siide Onlyy to Itsself Not to Th
he Easy Side]] Tre
eatm
ment: [Froom Heere Outt - Com
mparre Harrd Siide Onlyy to Itsself Not to Th
he Easy Side]]
Hard TMR # Rank Hard TMR # Rank Hard TMR # Rank Hard TMR # Rank Hard TMR # Rank Hard TMR # Rank Hard TMR # Rank Hard TMR # Rank
1stt Exerrcise Hard Side = TMR # What did you do
o/ho
ow ma
any/ho
ow long? TM
MR # What did you do/how
w man
ny/h
how
w long? MR # What did you do
TM o/how
w man
ny/how
w long? TMR # Side (1100) Side (1100) Side (1100) Side (1100) Side (1100) Side (1100) Side (1100) Side (1100) 1stt Exerrcise Hard Side = TMR # What did you do
o/ho
ow ma
any/ho
ow long? TM
MR # What did you do/how
w man
ny/h
how
w long? MR # What did you do
TM o/how
w man
ny/how
w long? TMR #
D. ARM RAISE
get toy
Cha
ange in
n Impairrment Hom
me Progrram Des
scription
n of Po
osition/ Mottio
on Th
herap
peutic
c Play - Ea
asy Side
e Cha
ange in
n Impairrment Hom
me Progrram Des
scription
n of Po
osition/ Mottio
on Th
herap
peutic
c Play - Ea
asy Side
e
Treatment: From here out, COMPARE HARD SIDE ONLY TO ITSELF, not to Easy Side. [All exercise is to EASY SIDE.]
Cha
ange in
n Im
mpaiirm
men
nt Hom
me Progrram Des
scription
n of Po
osition/ Mottio
on Th
herap
peutic
c Play - Ea
asy Side
e 5 Treat Cha
ange in
n Im
mpaiirm
men
nt Hom
me Progrram Des
scription
n of Po
osition/ Mottio
on Th
herap
peutic
c Play - Ea
asy Side
e
E. LOWER TWIST
Bounce on
2nd Exercise Hard
Side
TMR #
(1100)
What did you do? How many? How Long? TMR #
(1100)
Easy
Side
Home Program (Position Treat Play) Knee
F. SIT-TO-STAND
3rd
d Exerrciise Hard Side = TMR # What did you do
o/ho
ow ma
any/ho
ow long? TM
MR # What did you do/how
w man
ny/h
how
w long? MR # What did you do
TM o/how
w man
ny/how
w long? TMR #
LEG
3rd
d Exerrciise Hard Side = TMR # What did you do
o/ho
ow ma
any/ho
ow long? TM
MR # What did you do/how
w man
ny/h
how
w long? MR # What did you do
TM o/how
w man
ny/how
w long? TMR #
Cha
ange In
n Impairrmen
nt Hom
me Progrram Des
scription
n of Po
osition/ Mottio
on The
erapeutic Pllay
y - Easy Side
Cha
ange In
n Impairrmen
nt Hom
me Progrram Des
scription
n of Po
osition/ Mottio
on The
erapeutic Pllay
y - Easy Side
Signature
Copyright 2012 Susan M. Blum
Keep It Simple !
"*"&''%&'%('(%! #'
) !'"(!'"!"('" &3
Verticality Verticality
Side to Side Verticality
Sacral Sitting (basket) Retest -
Front to Back Verticality If Still Restricted
Level with Lift
To Keep Upper
Body Vertical
Restricted Side
Copyright 2012 Total Motion Physical Therapy Total Motion Release and TMR are trademarked by Thomas Dalonzo-Baker
?
#'#.--.)).",'/-&!,)/*->#-/-(1%(--8>3
(0,+/#,').),)(.,)&#(,-1#."*).(.#&,.#(!-*,.
"* '(!'%'%&'%'"!&#%"()! "% !
*,)&' ,)'#(#.#&#!()-#-
!#% !!', '$(&'"!"#"'!' "'"%"!'%"3
?3)'*)/( .-) #!()-#-@"#&1#."0&)*-(.,#),
P&2#)(,-.,#.#)(#(.,/(%> /,.",&3-2.(-#)()(.,)&>'3
?)/(.#)(,))%,.-/(-.&-) -/**),.8 .%&)(!,.)&,(.)-#./*5=),'3(0,"#0-.+/&#.3
?
(#&#.3.)/-*)1,) 0,.#&)(.,)&@.##6-,/'6."),2A ), *)-./,A
&#!('(.) -/*,#),-.,/./,-
?/*,#),)(.,)&&#'#.3/(-.&-) -/**),. ?2--#0-.#.#)((/-'),,-.,#.#)(-@"#&1#."
-*-.##*&!#'3*,)(. ),,'.)'#(.#(*&0#)(.,)&(
? 3*,')#&#.3(#-.),.)31,(--(&( &)-*).(.#&/**,2.,'#.3)(.,)&
?
%) --.)')#&#.3(.)0&)*+/#&,#/',.#)(- ?
(.,(&,-.,#.#)(-G9'3#'*.
')#&#.3(').#&#.3
-)"#&!.--./%1#."&#'#.")#- ),.,(-#.#)(-
? 3*,')#&#.3,-/&.#(!-)(,3.)"3*)')#&#.3'3*,)/ ?"#&1#."-,&-#..#(!0&)*-%3*")-#-(,0#&
"3*,2.(-#)(1#."-*"6(-1&&)1#(!#--/-8A
*#(
?)'#((3,&#(()0,*(()(.,*-().", ?/,.",,#( ),'(.) /(-#,*..,(-7@-,&-#.O-"),.6
1%-6*&(.,P&2#)(O-"),.61%!-.,)-A
+/#%&3,,/#.'/-&-)'*)/(- /,.",#'&(8
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)(!.,'#'*.) #'')#.#)(;)& <-
1
?@-#.)'/-&.))('3(,)..#)(&)-.).)'3A
Beverly Cusick - Body adapts to history of use
NOTE: The session doesnt end when
they walk out the door
Explore not Impose
NEURO-PLASTICITY !!! For the next 2-3 days the patient may feel
something not before experienced and
begin to access new motions
NO Zone NO Zone
GO SIDE GO SIDE
Pre Tx Post Tx
video
Copyright
C h 2011 Total
T lM Motion Ph
Physicall Th
Therapy TTotall M
Motion Release
R l and
d TMR are trademarked
d k d bby Th
Thomas Dalonzo-Baker
D l B k 63
6
20 months TMR
36 months 11 months
16 months Lucien at 48 months
40 months 15 months progress
42 months 20 months
Climbing jungle gym
Tongue surgery
The drive to achieve the upright position is served first by vision in the very young infant, and soon after by these
processes:
Nervous system maturation - proceeds from head to hips and from torso out to hands and feet
Muscle activation gradually gaining both organization and strength to resist gravity
"* '''#%)!'%(%%!"%&'%'"!3 The combination of muscle strength in extension and flexion to produce and control weight shifts
through the torso, shoulders, and hips in all positions.
Cusick, 2012
TheraTogs -Wunzi to maintain 75% of new posture
Maintains upright for perfect practice
LABS:
Treatment
Steps
Like a Food Pyramid
" %"% &.,#%' !'&&"!& C. How do we
empower caregiver &
)1.)/-').#)(-#(*&3 make it fun? TEACH 1
$.#0-) "0#-#.
B. How do we fix it? TREAT 2
A. How do we pick
TEST 6
whats limiting ability?
Copyright 2011 Total Motion Physical Therapy Total Motion Release and TMR are trademarked by Thomas Dalonzo-Baker
Dalonzo Baker
Easy way to have parent do twists
Combo
Left Upper Twist/ Right Lower Twist
Back Chaining
Child on right side
Replicates Pattern of Walking
Copyright
C h 2012 Total
T l Motion
M Physical
Ph l Therapy
Th Total
T l Motion
M Release
R l and
d TMR are trademarked
d k d by
b Thomas
Th Dalonzo-Baker
D l B k 58
5
Identify factors limiting progress - less active (car seats, fatigue, illness)
Challenges in posture limit energy to learn & may effect all systems
Treat 2
Teach 1 - fun way to incorporate into daily routine 24/7 - position/ play/ release
Use multi- sensory: hand over hand, doll with tape, parent feels on own body
Tots 2 Level - Side Bend, Upper Twist, Lower Twist, Arm Raise
Right Elbow to Left Knee
LAB:Try Total Motion -
How can you use your body tip to toe?
(Like Spiderman shooting webs)
Copyright
C h 2012 TTotall M
Motion Ph
Physicall Th
Therapy TTotall M
Motion Release
R l and
d TMR are trademarked
d k d bby Th
Thomas D
Dalonzo-Baker
l B k 38
Try with Doll - Crunch in Right Side Bend Contraction into
Adding Resistance to Release Direction of Ease with Gravity Resist for Active Release
RESPOND
Treat 2 , Teach 1
Sensory to Hard Side
Organize (Integrate, Activate, Attention)
Follow Through - Customized Home Program
Torticollis
Tape Your Doll
video
Tape dolls PRACTICE ALL MOTIONS
Front right shoulder to left ASIS
Back left shoulder to right PSIS Demo on Self
Side left axilla to left ilium Demo on Doll taped
Screening for Torticollis Related Restrictions
Cant touch
left elbow to
right knee
Why treat the base & not the neck? (Focus on T/L and L/S)?
Lets look at Tort
How do you Pot a Plant? - Grab the petals or the root ball!
from a different
perspective
What if we ignore
those sites?
Compacted Soda Can = Baby in Womb
Compacted Soda Pop Can
THE EQUAL OPPOSITE ACTION What if we treat neck and miss the root?
(Torticollis - a misnomer) really Tortisoma
L TD L TD
L SB R SB L SB R SB R BU
R BU
Typical C Typical Reverse C S - Bottom Up w/ TD S- Top Down w/ BU Typical C Typical Reverse C S - Bottom Up w/ TD S- Top Down w/ BU
Copyright (c) Susan Blum PT 2013 Copyright (c) Susan Blum PT 2013
Best and Worst Case Scenarios
Grade 1 vs Grade 4 Development of Righting Reactions
Compatible patterns = Twist and Side Bend to Same
Explore: Which can the child work out himself & Side
Which will be a tug of war?
Family & Child can work on sitting balance with help of SI
once taught therapy positions to reinforce therapeutic play
vs
Incompatible patterns - Twist and Side Bend to Opposite
Sides
AA B C
A B
C
A
Child C Child A Child B
A B
C
3
(+2)
C A B When a child with a
Level 3 Bottom Up Side Bend
l (J restriction) 4 3
Pulls to stand the head & shoulders
Level Level Level may try to level creating an S curve
Cheyenne - Grade 1
Grade 1
Brandon J -L tort -visit 1- side bend & upper twist - limited Brandon J visit 3 - neck now almost straight but lower twist
rolling shoulders to right / pelvis to left tight to left - treat and play with R LT segmental roll on bed
Brandon J - Grade 1 Brandon J - visit 14 - neck balanced - symmetrical squat & cruise
still pull to stand on right (seen 2 more visits to resolve)
care plan
Week 1- Upper Twist and Side Bend
Week 2- Lower Twist (issue resolving in neck, but stuck in pelvis)
Weeks 3 -12 Various combinations of Twists and Side Bend
Brandon learned to crawl but as pelvis rotated to right was dragging left
leg & cruising to right only
Week 12 - Crawling flexing both hips
Week 13 - Lower Twist
Week 14 - Symmetrical squat and cruises both ways - Needs better
lower twist for symmetrical pull to stand - Mom says we will track- she
can handle it!
Visit 15 Brief check in to track - continued progress
Visit 16 - Discharged
Curtis visit 12
visit 1 -L tort- Unable to sit or commando crawl, delayed
protective response, tightness in neck and pelvis (twist- 60%)
Ranges all within functional limits visit 3 - Symmetrical sitting and balance - head upright
Symmetrical sitting visit 5 - Rolled both ways - dragged left leg and arm trying to
commando crawl
Symmetrical crawling visit 9 - Symmetrical creep on all 4s
Plagiocephaly dramatic improvement visit 10 - Discharged (intensive Home Program)
Brandon H visit 2 ( visit 1 was UT - now SB/LT) Brandon H - Visit 10 Motion for Release and Function
note: By visit 9 symmetrical crawl Side bending left easy to lean on right arm
B A
Grade 4
Grade 4
Top & Bottom R Side Bend /R Lower Twist Try to sit and Child A - Grade 4 w/ more lower part of SB
balance! ( His has more Bottom Up)
video
London Grade 4 - UT and SB to opposite side = incompatible
child tries to shorten one and it tightens the other as she tries
to develop righting reactions
Future visits:
Parent continued
with same UT and RSB
until fully released
2. High with occasional
3. Medium PT visits
to tune up
1. Low
This is what I did for first 2 years, but got Grade1 + Extension = Level 5 Grade 2 + Grade 3 = Grade 5
better results when fine tuned
You can still treat, but try to feel what childs Too much for most caregivers and Tots 1 level therapists
Most Complex
want body wants to do. When doubt keep
the other 1/2 of the body neutral! = restriction Restrictions in Additional Dimensions
Many Possible Combinations
Copyright (c) Susan Blum PT 2013
Head position may have different trunk issues Possible Asymmetry Patterns in Torticollis
Left
Cant assume what is limited - Need to test all 6 Upper Grade 1 Grade 4 Grade 3 Grade 2
Twist
Grade 5 = Grade 5 =
Grade 1 + Severe 3 + Whats happening Below
Extension Moderate 2 L TD
L SB R SB
Note Line of Pull R BU
External to Body
2) Relates
Typical Cto Head
TypicalPosition
Reverse C Typical S - Bottom Up Typical S- Top Down
Right
3 Upper
Twist
R TD
R SB L SB L BU
Extra Dimensions
Grade 5 = Grade 1 plus extra dimension Severe Complex = Extreme Treatment
Left
Lynnia - 5 months of TMR pre and post
Upper
Twist using treatment of lower trunk rotation
Diagonal Extension
L SB
Typical C
insert
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nse
serrtt cclip
liip ly
lip llynnia
yn
nnnia
ni
ia iinn Ap
A
April
pril
ril
ri Typical C plus extension pulling left scapula down and back
Intense prolonged Active Upper Twist while hips held in Lower Twist
(Didnt tolerate any other handling)
Listened to her body that wanted to extend & supported her in that position
Just do
Extension L UT on top -
BU with R LT no SB!
Grade 3 = J pattern
(Child B) Grade 5 with Mild S plus extension Severe Combination Pattern - Aryana
Grade 3 right BU side bend (+ Mild 2 left TD side bend Week 2 7 months treatment to pelvis
Keep top
neutral
Focus on
BU
Combo
LAB Left Upper Twist/ Right Lower Twist Was there an S under the C?
with or
Child on right side
doll: Does an S develop as compensation with gravity?
WALKING
Upper 1/2 side bend can drop left arm pit with flexion
(Right top down is hard side) tested sitting Doll lab: Moving with the child
Lower 1/2 side bend can hike right hip with extension
(Left BU is hard side) tested standing Listen to Child - Upper Twist may go
further with extension if that is another
restriction
Needed Bottom Up / Extension one week
Bottom Up only next week
Crawled the following week Multiple layers
change as you
progress though
releases to her
core restriction
(R-BU-SB & Ext)
a portion of her somatosensory mapping has been created around the dysfunction. During
times of stress, such as growth , the mapping returns to what it thinks is normal.
(Carreiro 2009)
video
vid
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de
deoo vid
vi
video
vide
iide
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Flexion Restriction Grade 5
Upper Flexion/ plus
Lower Extension Restriction
Left
Sternum
Rotated Right Hip
Hiked Right
Right Right Pelvis
Pelvis Pelvis Retracted Left Hip
Retracted Retracted Right
Pelvis Hiked
Right Hip
Retracted
Adducted
Copyright 2011 Total Motion Physical Therapy Total Motion Release and TMR are trademarked by Thomas Dalonzo-Baker
Copyright 2011 Total Motion Physical Therapy Total Motion Release and TMR are trademarked by Thomas Dalonzo-Baker
Initial
L UT
Issues
L SB
Initially #1
Ext
R LT
How to get tummy time?
Almost Ready
for Discharge
Narrowed the
field to
LT & EXT core issue
.##(*,0#)/-*)-./,1"(-.,--6#&&6!,)1."6
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Carreiro, J. E. 2009
Active Play in Sidelying using his UT Direction of Ease
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Missing Ingredent:
Release & RoadBlock
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Copyright
C h 2011 Total
T l Motion
M Physical
Ph l Therapy
Th Total
T l Motion
M Release
R l and
d TMR are trademarked
d k d by
b Thomas
Th Dalonzo-Baker
D l B k )(.,)&;
Medium %
Moderate
Low %
Minimal Goal
Copyright 2011 Total Motion Physical Therapy Total Motion Release and TMR are trademarked by Thomas Dalonzo-Baker
Support to maintain new normal
Hypotonia = More restrictions - Need stacked with symmetry "*&'&"!#'##'"',#&
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My teachers!
Additional Thoughts
Cant do all 6?
Child Fragile
Lets Experiment
My mission
Clinical Expertise
David Sackett
I just show them who they have always been
Briefly discuss impressions
and if they buy into it, we make magic. (Kim Curtis )
How has your thinking changed?
What are you going to try with your special patient?
or
What happened to you?
Final Thoughts