Untitled - Susan Blum

A Taste of Tots for Torticollis
Total Motion Release for Tots

Treatment of children with postural imbalance and
associated motor impairments with Total Motion
Release, an innovative indirect concept
Developed by
Susan M. Blum, PT
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
(demonstrating)individual clinical expertise

(reporting)..more effective and efficient diagnosismore These are your only important slides
thoughtful identification and compassionate use of
individual (requested & reported) patients The rest are my cue cards
predicaments, rights, and preferences
(Sackett et al 1996, Evidence based medicine: what it

is and what it isnt. BMJ, 1996. 312(7023): p. 71-2.)
Ask, Listen &
Respond
Who are you here for?
What does their body

want to do?
Osteopathic Approach
Treatment Order for Homeostasis
Lauren Noto-Belle, DO
Autonomic Arousal Level - Regulation

Innovation is not the product of logical thought Somatosensory Dysfunction
although the result is tied to logical structure (Attermeir 1994)
Albert Einstein Lymphatic Fluid Balance - Delayed Healing

= Fibrosis &/or Adhesions
(Ettinger & Willard 2010)
Innovation: Tom developed concept based on established

Myofascial Fascial Restrictions
osteopathic principles (Willard, Fossum, Standley 2010)
Logical Structure: He organized it with precise scientific
method to determine most effective motions for self
Articular
treatment
What is the dog doing ?

The deep fascia of the limbs is a sheath presenting a mean
thickness of 1mm, formed by two to three layers of parallel
collagen fibre bundles.
In the adjacent layers, they show different orientations.
Each layer is separated from the adjacent one by loose
connective tissue, permitting the sliding of the collagen layers.
Nerve fibres were found in all specimens, while muscular
fibres were evidenced only in one specimen.
The described structure permits the fasciae of the limbs to
have a strong resistance to traction
Stecco 2007, 2008

Why is the dog happy?
Ask, Listen &
Respond
Tell kids we have one big rule
The No Owie Rule
We only do happy treatment
We only do Cozy Positions
No Pain!
What do you do if you have a belly ache?
Flexion is the healing position!
TMR
Concept
Thought for the day:
You are invited to

explore a new way to
FOCUS
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
Where lacking STRENGTH & CONTROL?
First look at RESTRICTION
Now first ask:
Where is MOTION RESTRICTED?
The restriction was limiting ACCESS to the

development of strength and control.
How is TMR different ? How is TMR different ?
A1. For children with torticollis

A2. For children with other issues in detail= TMR Tots 1
THE PREP WORK PHASE = The Launch Pad
Getting Ready Work for therapy you are already doing
Balance the Body in Symmetrical Alignment

B. THE ACTIVE PHASE = Improve Motor Control
Structural Symmetry & Fine Tuning with 3-D and active motions
(Seminar Objective - learn how to do this in trunk = TMR Tots 2
rotation for children with torticollis) (we will discuss tomorrow, but only introduce ideas)
TMR is what we already do as pediatric PTs

Organize what you already know
We have many great choices of techniques to approach an issue
Structural Balance -
vertical & symmetrical
strength &
Q: How has the Tots concept been developed? range of motion vertical /upright posture
A: COLLABORATIVE EFFORT with expertise of many pediatric PTs cross transfer Rood (flex/ext, proximal/
Based on adult TMR which was developed by Tom Dalonzo Baker neuroplasticity
distal, stability/ mobility)
(q 2 hours) Bobaths (elongate, rotate,
wt shift)
Q: How can we minimize need for more/ future treatment? methods used in
orthopedics - SCS UNITIVE Knott & Voss
A: EMPOWERMENT (caregiver and child to manage issue) (3-D patterns not isolated)
motor learning METHOD
Sahrmann
Q: What has been positive feedback from therapists using this concept? natural environment
(hypomobile /hyper)
A: CLINICAL EXPERIENCE - positive objective results each visit daily routine - positioning
Kendall & Kendall
& PARENT PREFERENCE = (EBP) personalized - customized to
Fay
needs play - happy child (fun!)
Shumway-Cook (vestibular/
Q: What is my objective? Physics 101 (long typical
balance)
levers, Newtons II law) development Sensory
A: RESULTS (quick and most complete) - Does my current approach Gentile)
provide consistent objective change within EACH SESSION?
HOW TMR IS DIFFERENT
1. Uses a systematic Form developed scientifically by
Tom Dalonzo-Baker to identify and prioritize treatment TMR Tots started with a little boy name Lucien
Massive soft tissue restrictions - torticollis & hypotonia
2. Uses modified Strain Counter Strain / Positional Release
Did you ever ask yourself WHERE DO I START ????
(Jones, 1995, Wong, 2010, Chaitow 2007)
Weve used for a long time with adults
We just havent had a way to teach parents or caregivers to so

this or to use in pediatrics
Engage Unlatching principles
Indirect technique to release restriction by encouraging motion in direction of ease.

(like a latch on cabinet that you push in to release the mechanism)
Shift in Focus - Simple Care Plan

8 Step Teaching Form used for course ,!'%'!(!0
instruction & may be used for detailed progress note
Total Motion for Tots 8 Step Form
"*'")"'%&*'&'"%'"&2
Nam
me DOB The
era
apis
st Da
ate
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]
"%&,&' '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)
!%&'!*,&" &'"!%"% ')

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 #
!" #'%&('&
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
w man
ny/h
how
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
w man
ny/h
how
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
"%!%'"!"&7" "%'= ""%%&2 ,"!>'*''%'!'"%'"&*'&'%'!0
<'##%"&&#%")&,&' '7"7 '&' "&'(%%!'!"% '"!"!$( !(

>!'#%"&& &'%'!3

"'",&&&& !'&"*"!!'"!*' "*!*&(%'%&!"#!*!'%'!
(!'"!7)"# !'&&(& 35"!"% 26
( %!%"&'%'"!&+#!*,&" "*"&#%""!&'%'!8&%&'!9%
&'"!%"% ')!" #'%&('& %" $(&'%''"&'%"&3
#',.(!!(&'" #"*% &'" "*"&'%%" &'%"&3

!!(!'",%"('!&
M
Manual Stretching - If the evidence says it doesnt work in one
area of the body....
How can it be the best option in another ?!?
Stretch does not have clinically important effects on joint

mobility in people with, or at risk of, contractures if performed
for less than seven months. Katalinic 2010
What about shortening for patients with

neurological conditions?
Feel restrictions Left Side Shortened / Shoulders to Left
1. Tuck shirt at front/ center.

Try to stand up tall = Tape on front
Hang forward to slowly touch toes w/o
stretching = Silly Putty on back
2. Stand and tuck in shirt on the left side

and in the front left side at waist band
Try to rotate chest to right - feel
restriction = Tape
Try to rotate chest to left = Silly Putty
"!&%'"!!'"!'*! 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:
1) Health Condition (dx): 1) Health Condition (dx): CP - BLEs R UE?

2) Participation (Restriction):
Play with friends at daycare
2) Participation (Restriction):
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
Wheres the restriction?

Zoom In Wheres the restriction?
5) Contextual Factors: 5) Contextual Factors:
Copyright 2012 Susan M. Blum Copyright 2012 Susan M. Blum
TMR Tots 8 Step Form

Nam
me Therrapis
st Datte The Problem with Asymmetry
Parrent/P
Pattientt Con
ncern
n - Activ
A vity Limitation
n
Describe Function: The body adapt to its history of use
Cant Sit Falls to left after 1 min
Tes
sting
g: [Thee Reestt of Body for Asymm
metrie
es - Test Le
eft vs
s Rig
ght] [You
u can
nnot have the sam
me %s mo
ore th
han once]]
Inadequate acquisition of the two fundamental ingredients of
Side Bending: Function vs Structure
antigravity trunk, neck, and hip extension first, and then flexion
Cant get wt bearing w/o elongation leaves balance, weight shifts, and movements compromised.
F. LEG DANGLE STAND to SIT
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
Bungee Cords = Restriction in Motion
"*"*)"#' &, '%,3
Find soft tissue restrictions limiting range (TAPE)
Identify and describe as precisely as possible on

8 Step form
3-D Use principles of modified Counterstain to treat by
Rotation, Elongation and Shortening UNLATCHING the restriction first.
Consider how one small restriction in a

green motion can limit development
Case Study Child with Torticollis
Age: 3 mo referred tp EI - Dx at well check up:

left CMT & plagiocephally
Hx - Mom low on amniotic fluid
PT initiated @ 4 months
Torticollis: Neck zero lateral flexion to right,
25% rotation to left
Tortisoma: Severe generalized throughout body.
20% thoracic rotation to right 15 % pelvic
rotation to left, 0% lateral trunk flexion to right
Visit 1
Visit 2
Video of mobility in trunk
We now measured w/ photos - now supine (Rahlin, et al. 2010)
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
All my assessment & treatment is SLOW!!!

Focused Active Release in Upper Twist reaching for Elmo
Thoracic Rotation Deeper to the Left when Pelvis stabilized
"* '%&'%'"!&)"#3

'')#&#4.#)(@1)'"/&.4@EMMJA6
(*,)&)(!
&#'#..#)(-#(*)-#.#)(#(!)*.#)(-/.)#&&(--61%(--6
"3*).)(#6)(.#(,%#-6.AO)'*(-.),3*.#0
"),.(#(!
'#-/-6)0,/-6#-/-6#--(.,/'
Checking all motions - Identifying tightest spot in chest

Matching the motion - Impact on Lift
Note: Intensity more than usual
Fetal somatic dysfunction resulting from increased intrauterine
pressure limiting fetal movements including differences in levels of
amniotic fluid, multiple births, intermittent uterine contractions, Immobilization is the villain
maternal pelvic somatic dysfunction. _____
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!
Ask, Listen &

Respond When I say Child is in Left Upper Twist that means that the left is
the easy side. His Asymmetry Pattern (Lesion Pattern) is to Left
= Midrange is to the left of neutral
(We grade how limited it is to the right (in direction of barrier)

What does their body want to do? relative to direction of ease of then treat to the left)
There is a reason it is posturing that way
This helps you find restrictions
The Green tissues are extensible like Silly Putty

(Note pull on the bias on line of clothes as
she rotates further to the left with ease) TMR is an Indirect Technique
In Osteopathic Terms
But the Red line (restriction) is like a tape band limiting Indirect Technique = Treatment into Direction of Ease LUT
right upper trunk rotation Vs
Direct Technique = Treatment into Direction of Barrier R UT
We move into the direction of ease (no chance of Pain!)
We use the rest of the body to indirectly correct the restriction

(Long lever arm)
We can indirectly shorten a restriction by using contralateral

lengthening
12 Range
11 1 e Pie Charts
Midrange
g New Midrange
When I say Child is in Left Upper Twist that means that the left is
the easy side. His Asymmetry Pattern (Lesion Pattern) is to Left HARD H
= Midrange is to the left of neutral 10 Side 2 S
EASY SIDE EASY SIDE

We grade how limited it is to the right (in direction of barrier)
relative to direction of ease then treat to the left 9 3
NO Zone
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
Match the Motion
Test Tx
Test Tx

Nam
N me DOB The
era
apis
st Da
ate
P rent/P
Par Patien
nt Con
nce
ern
n
#1 Listen & Respond 2. What ACTIVITY is Limited Related to Restriction?

Testing
me # morre than onc
ce]
Ask, Listen & Respond

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 Ask Parent - What is concern?
Ra ard TMR # Rank 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] 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) 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
he Easy Side]]
1stt Exerrcise =
Hard Side TMR # What did you do
o/ho
ow ma
any/ho
ow long? TM
w man
ny/h
how
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
o/ho
ow ma
any/ho
ow long? TM
w man
ny/h
how
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
)1 & .) ,-.,#.#)(-)(-& #(."#-*)-./,
,'3,1&
E=F(&
,/#-
")/&,P&2#)(

LAB: Feel some additional restrictions on self
Side sit on floor arch of foot on knee '&'&,&3

Turn right and left with hands on floor
Raise arms above head and rotate (.#0&3)(.,.'/-&.)')0.",)/!"
How deeply can you breathe? !,.,,(!,&.#0.))**)-#.-#
7& .-#(#--3-#.".-"),.(-'),
Now switch to the opposite side sit position/ ."(,#!"./-,#!".-#&)(!.-'),1#."
Repeat motions - How does this differ?
!,.,.#--/2.(-##&#.3."(& .@,-.,#.#)(#-(<.
Where do you feel more restrictions?
(--,#&3#(."-'&).#)(A
On easy side: Document how far you can drive a toy car to die
with arm on knee forward side

Document asymmetry you feel in trunk -

How far off the floor are knee, ischial tuberosity -
How far off center is umbilicus from pubis, sternum from
umbilicus?
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
Can actively shorten left side, but restricted to right

Left side doesnt elongate to allow right side to shorten
Assessment: Zoom Out / In to Assess

Where are her midranges
What is structural limitation and functional limitation? How restriction impacts functional activity
What do we need to crunch & unlatch?
2 A. What cant they do? 2 B. What is getting in the way?

Activity Cause- Restriction
Cause & Result - Shirley Sahrmann
"*! #%") "',!"!% #%")")% 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 (&."#(! .
Structural Imbalance "*&%!''!"&'"!&3
Poor/ Distorted Foundation to Develop Motor Control L-#').#)(->&)!#&6 P##(.G'#(/.----'(.

'#&3=.#(.,#(&3>FH=K>'*)1,'(.
Limited Success in Development of Full Motor Potential ",*/.#&3.8.)#(),*),.#(#&3,)/.#(-
'').#)(-/- ),0&)*'(.) ').),)(.,)&
Musculoskeletal Changes (Wolfes Law)
(#,..,.'(.9(,) .")3'3/-.)
!#(,(!#(().",/-#(!&)(!&0,,'
(Cusick B. An Open Letter to Caretakers of Children with Diplegic Cerebral Palsy )
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
CONTRALATERAL LENGTHENING - Use Antagonists and the rest of the body

to go deeper into a release
THERAPEUTIC PLAY - Active Motion to shorten further to unlatch restriction
Posture in Adults exaggerated in Children with Developmental Delays

Fascial Chains - Anatomy, Treatment & Dysfunction (Paoletti 2006)
Anatomy Trains - Myofascial Meridians (Myers 2014)
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
Tonic muscles contain more perimysium & are therefore

stiffer than phasic muscles
In vitro contraction testes showed that fascia can actively
contract & that the resulting contraction forces may
influence musculoskeletal dynamics.
The pronounced increase of perimysium in immobilized
muscle & w/ skeletal traction indicates that perimysial
stiffness adapts to mechanical stimulation, influencing passive
muscle stiffness
The existence of pathological fascial contractures
(Schleip, Naylor, et al 2006, Schliep, Klinger et al 2005)
Objective find and treat the most hypomobile first

before trying to fix over lengthened issue T
The PREP work makes anterior myofascia more extensible
Shorten the Short Stuff

ff To Better Shorten the Long Stuff Shorten the Short Stuff
ff To Better Shorten the Long Stuff
Traditional PT Traditional PT
TMR TMR TMR TMR TMR TMR
Prep Phase Enhanced Traditional Dynamic Phase Prep Phase Enhanced Traditional Dynamic Phase
"*!*!#%">!,!'%'!!
&'!!'"#'!'4&",3
"*!*$(,!',' "&'%&'%' ?-.,)(%3').#)(**,1#-.

%3
?----#,.#)((0,#.3) ",-#
"),'>L-#').#)(-@
(&/-F1. ,&.#0.)-3-#
,#(!A5=),0#-/&)-,0.#)() "#(!
",#-.".*;",#-.")1-.,#(!; ?-,01",#-."'#,(!) ,)..#)(
? ,(&*.#)((&-
?)."(!#(,,#,( /(.#)(8
What is Contralateral Lengthening?
Lets Try an Example of TMR on Ourselves
LAB: Upper Twist
(.,.'(.-".1#."-,#*.#)() ').#)(-A

ED

Ask & Listen

Where is Tape?
Where is Silly Putty?
Where does it start & end?
Relative to YOUR Easy Side how
We actively lengthen one side to indirectly shorten the other does Hard side compare?
Note: Adults may be harder to assess than children-

Have overlay of more orthopedic issues
Be sure you are low enough on your ribs! May have developed hypermobility in shoulders to
Do NOT twist your neck. There is no stress to neck with TMR.
compensate for limited upper twist
It just goes along for a ride and follows the trunk
Both sides my seem the same, but a segment of one
The Upper Twist on child is the easiest to identify direction may not feel as elastic as you hit barrier of
tensile strength of tight fascia.
Lower Twists may seem the same or Both may be

murky (one side stiff/other side hurts)
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
Objective is that parent can pick the motion

Low %
with the most imbalance
Minimal Small GREEN Goal (most red - most severe imbalance)
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
What if one side is limited in range but the @#!".0-8 .A

other in is painful or weak?
This makes the motion MURKY "*)%3
If both have issues neither is the easy side
Mark with a @#!=#/'='&&O=&&)1=,(A
*
Babies are special Less is More Ask & Listen

Always treat like Eggs! To be able to palate the direction of
ease in the Upper Twist on Patient
If you only master upper twist and can use Monday AM to check
children you will have success! That is Course Objective!
Rotation is usually the biggest area of hypomobility & connected to

other areas
Build on this with other motions as your comfort level expands

Objective
Patient with Rods or Osteoporosis Can Be Treated
To develop an appreciation of precise non-intrusive palpation Respond or Suggest - NOT Impose Force
$.05 on Fingertip - Top of hand - Forearm WE ONLY LISTEN & SUGGEST
Examination without provoking resistance There is NO rotational force
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
May just gently stroke over muscles superficially to relax and

suggest movement
LAB: Hand over Hand

To develop an appreciation of precise non-intrusive palpation cont. How to support partner for each motion & See how lightly you can hold and still feel
We dont make a choice for them or tell them to do something they are not ready to do
Honor Them
Its not about us - Be sure we arent trying to prove we are doing something
Twist like putting on Body Lotion or cream The Language is Comfort

Try holding Oatmeal Box to practice
Place heel of hand gently on an anchor on back The 3

4 Ss
Finger tips on front below nipple line
1. STABILIZE
Back Front Both
2. SWEET SPOT Palm
3. SLACK Silly Putty
4. SOFT
Dalonzo Baker 53
Practice treatment with a fragile person

How lightly can you hold and still feel easy side?
Pretend you are wearing mittens
Just breathe and do clothing within their available range
gee
DONT IMPOSE MOTION!
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?
What systems are controlled from lower thoracic area?
Treat with ELBOWS not hands!

Touch / Lab
Respond not Impose "*!
$(,'%!&%'&"!#'&'"
%)%3
Learning to Play a Piano
Do one hand at a time then both /#.),3(0#-/&/-6
We will talk through process (',%-6
()0,"(6
#(#'#4#&)!/6
Be soft and light - no claws- no ping pong paddles *)&&.),*&#."#&<-#--/6
,3)()1()3
If too heavy are you doing it for you trying to prove you
are doing something?
Body doesnt want to do something its not ready to do
Ask, Listen & Discuss hand placement with partner explore

Less is more ribs like balloon
Respond Feel intercostals
Have partners feel your motion and compare
findings with each other (if time try another arm
raise or leg lift)
Discuss why you called it a color (range, pain,
LAB OBJECTIVE: speed etc.)
To be able to obtain rotational tissue release of the
mid/ lower ribcage using TMR treatment Ask instructor for feedback 1:1
Listen with your hands and observe response in patient When done rotate to another group or try side
to determine your response bend
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?
Effect of inferior on superior

Head
H rights in neutral when base (side bend) corrected
Plate on a stick at the circus or bowling

ball on a pencil - vertical structure not
yet with strength can still balance.
Prep work of TMR makes spine more

symmetrical & vertical so he could begin
to develop head control
in an expanding range.
Compacted Soda Can = Baby in Womb
Elbow to opposite knee - Which goes further?

What is his preferred Upper Twist?
(Pope, R 2005)
Compacted Soda Pop Can
>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)
Modified- on chest prone Lower Twist

Ask & Listen
NOTE: FEELING & DESCRIBING RESTRICTION IS KEY!
More precision in palpation helps us identify

key restrictions for even better results
BUT dont stress about it!

Its a learning curve
Next week just which direction is ease?
Build on it as you learn
).7"#-1#&&)0,.() ---#)(
Note: THIS ISNT HOW I STARTED!

' "%'!"! "'"!&%"%3
Just do Upper Twist - Thats what fixed Lucien, Sorrell and all the
rest of children the first year! @EDD=MD=LDA-#,.),),."(
@ ,!N= ,!= ,!9A('3**&.)(!#(,*,(.-
Monday morning do: Which Side?
Week 2 do: Which Color?
Week 3 do: Which Number?
Week 4: Try another motion if ready
Add other motions ONLY once you get a handle on UT.

Dont worry about 1 vs 2. Just pick one as
Ranking = Herding Sheep everything in the body is interconnected
How does a long lever arm release a restriction

Find lamb the furthest behind #1 far from the area treated?
Find the next furthest behind = #2
Get the herd in alignment
Fascia is like the matrix of a fruit Jello mold
What happens to the fruit inside when you
touch one part of the mold?
Ranking
Sequence To Straighten the Blanket
Ask, Listen &

Respond
Objective
To familiarize yourself with the 8 TMR motions

Find Biggest Wrinkle by Listening to Childs Tissues
= logical Step by Step to find which motion to Target
CORE 4 Total Motion for Tots 8 Step Form

Nam
me DOB The
era
apis
st Da
ate
Parrent/P
Patien
nt Con
nce
ern
n Basic 8 - Core 4
Testing
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
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
he Easy Side]]
o/ho
ow ma
any/ho
ow long? TM
w man
ny/h
how
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
o/ho
ow ma
any/ho
ow long? TM
w man
ny/h
how
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
Pretest and Post test all 6 as in posture as on form

Indicate any differences in position used (eg: all 4s LT, sitting
in chair for LL, standing AR)
Elongation of Sides - Which side is tight? Which side bend is better?
Tots 2
S curves are TMR 2 level treatment
Top Down
At Tots 1 level only need to be aware of

difference
Bottom Up If you arent sure if its a full C or an S you
just keep the other 1/2 of the body neutral!
If in doubt - skip side bend and keep back
straight!
Same curve pattern

E
Elongation better on side opposite easy (crunch) side
Many children initially have a C Side Bend restriction
Adults and Kids after wt bearing often have or develop an S
L TD Top Down
Bottom Up
R BU
S- Right Bottom Up with LTD S- Left Top Down with RBU
S curves - Need to localize focus on area needing release &

Isolate the other area to keep stabilized and neutral
Copyright (c) Susan Blum PT 2013

On Back Standing
Nam
N me DOB The
era
apis
st
B
A. Upper Twist B. Side Bend C. Leg Raise D. Arm Raise E. Lower Twist )/HJ'DQJOHG. StandUP4JU H. Arm Press Parrent/P
Patien
nt Con
nce
ern
n
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)
S curve Side Bend

Sitting Standing Standing On Belly
Testing
me # morre than onc
ce]
Tots 2 B1 B2 Top
#.Top Down SB#. Bottom Up SB*. Flex/Extend +,. Bent Knee Toe -. Hip Shift .. Leg Lift Back Down
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
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
he Easy Side]]
3rd Exercise Hard TMR # TMR #
What did you do? How many? How Long? (1100) Easy Home Program (Position Treat Play)
o/ho
ow ma
any/ho
ow long? TM
w man
ny/h
how
w long? MR # Wh
TM
Side (1100) Side
S Curve Side Bend - Test Upper and Lower Separately

Mark which one more issue Upper or Lower
LAB: Side Bend
Adults may be harder to assess than children since

more S curves in back
Upper
Top Down: Depress shoulder to drop left armpit
Lower
Bottom Up (supine) Hips bent at 45 degrees Walk
feet to right and left to see which way lower body
Left Armpit Drops Right Side Crunches Up
goes further. Right Ribs Expand Like as Left Hip moves away
Mini-blinds from bottom of Ribs
TEST in Sitting TEST off FLOOR on Bolster, or Supine)
Note: On bolster harder to keep upper trunk horizontal

Optional Side Bend for children
Bottom Up: (sitting) On knee, bolster or

sideways on a chair with one buttock off the edge.
The side that drops further has more elongation
allowing the opposite side to crunch more. The
opposite side becomes the easy side.
Top Down Side Bend
Bottom Up Side Bend
Left Hip drops further

Right Hip drops a little
Left is side b
or Bolster Right is side of ease
b bend is the hard side
Lower Twist is the Pelvis (not hips!)
Children - Pillow between Knees

to protect Hips
Adult - Dog Hydrants
This is an easy modified lower twist

How does this differ from supine test? How might this be more
specific treatment for an asymmetrical gait?
8 STEP SAMPLE FORM

Nam
me Therrapis
st Datte
Parrent/P Pattientt Conncern
n - Activ
v Limi
vity L tation n - Caa lifft right le
an egg 6 in
nch hes offf flo
oor but
b t not
n yet
y able
a to le
eft leftt,
Can nt raisse left
l lleg to
t get
g up
up step
p intto Drag
gss left
ft leg
g when
nccrawllling. Marks titimee tto g
go up ste ep with
w rrail aand hand
h d helld lead diin
ng
livin
ng room with right
r t foo ot
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]
LEG DANGLE Test 6 on Self & Rank with Demo
Test with babies on back A. UPPER TWIST B.. SID

DE BEND
*C. LE
EG RAIS
SE D.. ARM RAIS
SE E. LOWER TW
WIST F.L
LEG DAN
NGL
LE
Back
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]
Treat with babies in arms R

Imp
65
Med
pairme ent (Bo
4 R 75
Big
ody Sttruc cttu
ure and
2 R Small
a Fu
45
F nctio on n) Walks
6 R Small
W s with
40
h rig
ght hip
7 L
h pulled
p ba
80
Big
ack an
and not
n be
1 L
end ding
60
Med
g left
ft hip - No
5 L
ot exxtend
70
0
Big
ding le
3 R Small
efft hip
35 8
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
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
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
Testing
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
SS
Treat in positions of ease

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) May add other motions of ease to go deeper into motion
EG: side bend
Tre
eatm
he Easy Side]] May move extremities as you let go
o/ho
ow ma
any/ho
ow long? TM
w man
ny/h
how
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
o/ho
ow ma
any/ho
ow long? TM
w man
ny/h
how
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
Testing
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
SS
Keep on Keeping ON
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
he Easy Side]]
o/ho
ow ma
any/ho
ow long? TM
w man
ny/h
how
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
o/ho
ow ma
any/ho
ow long? TM
w man
ny/h
how
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
37
LAB: Treating your self - Motion #1
Treating:
Start with Progress to DYNAMITE
TWEEZERS
softly lengthen excessive extreme end range

Silly Putty can stretch and tear!
Treatment
T
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
If we shorten a tight lateral trunk muscle,

it relaxes and becomes
more extensible
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)
Easy Side (front) - FLEXION

Hard Side (back) - EXTENSION
ALWAYS CONFIRM VISUAL WITH HANDS!

Discuss why - Child in chair rotated to Right was really
left Upper Twist but hard to see because of stabilization Extension Restriction
Ask & Listen - Move with the child - Dont restrain

Go where his body wants to go
and give him permission to shorten the way
his body is internally telling you to go
Tots 2 stacks dimensions 2-D, 3-D and
We can get complex combinations in the sagittal plane
EG: Left Top Down Flexion

w/
Right Bottom Up Extension
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
Shorten the Bowstring

There are many
more 3-D combinations
of restrictions with other
dimensions added
(child with brachial
plexus injury
pulls from left shoulder
to right foot)
Just LISTEN to
where they want to hinge
to treat
Ask, Listen & Respond
Documentation / Visit Objectives
1. What is Parents concern?

"*"&'<'#"% (>'%$(% !'
"%
&%))%,3 2. Find the #1 & 2 ranking motions as fast as
possible by checking as many as possible
3. Bring that motion into alignment
4. Show caregiver how to do the same

& how to incorporate into daily routine
Nam
me DOB The
era
apis
st Da
ate
Parrent/P
Patien
nt Con
nce
ern
n
8 STEPS - Every Single Visit
1 Focus 2 Functional Issue
Testing
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
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
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
w man
ny/h
how
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
Teach - Intervention teaches

Th
herap
peutic
c Play - Ea
asy Side
e
,(- ,#&#.3.)----.)*,(.
caregiver
(.,0(.#)(1#.".",*/.#*)-#.#)(-(
2nd
o/ho
ow ma
any/ho
ow long? TM
w man
ny/h
how
TM o/how
w man
ny/how
w long? TMR # ,&--.)#'*,)0,(! Treat 2
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 ,!(#4
----#,.#'*.)()$.#0 /(.#)(&
3rd
o/ho
ow ma
any/ho
ow long? TM
w man
ny/h
how
TM o/how
w man
ny/how
w long? TMR #
)/.)'#(---#)(*)-.#(.,0(.#)(
)'*,)!,'.))(.#(/.)#'*,)0,(!6
Cha
ange In
n Impairrmen
nt Hom
me Progrram Des
scription
n of Po
osition/ Mottio
on The
erapeutic Pllay
y - Easy Side
6 Limitation 8 Follow through ,#( ),(1(),'&(),!(#4 Teach 1

change Position/ Release/ Play & Organize
Cha
ange in
n Ac
ctivitty Lim
mittation
n
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
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
Organize using Wt Bearing motions Active Assist Organize Active Resist

Until the Core 4 are in Yellow Zone
Organize Actively in Vertical Intensely Organize
Nam
me
DOB The
era
apis
st Da
ate
LAB:
Parrent/P
Patien
nt Con
nce
ern
n
Try WB motions on self
Testing
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
SS
Speed/ Height On elbows/ On hands?
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
he Easy Side]]
Add challenge
o/ho
ow ma
any/ho
ow long? TM
w man
ny/h
how
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
What if you cant even go on all 4s?

2nd
o/ho
ow ma
any/ho
ow long? TM
w man
ny/h
how
TM o/how
w man
ny/how
w long? TMR #
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>-#.),&)-#.:
'"*"%'%&3 1. STAY in place and let body adjust to changes

,)(<.#'*)-:
2. ADD INPUT such as heavy work, jumping jacks, cross
, /&()..) ),'),."(."(10#&& midline to help child adjust to new posture and
,(!),').),.-%.".1)/&/- available muscles
/(-#,*)-./,#(!.".'#!".,#( ),
3. ADD Wt Bearing TMR Motions
,-.,#.#)(-
Support in Arm Press or Support in Sit to Stand -
Input Chains Through Entire Body
",!#0,-")1.)')(#.),3.)3
"(!-#(")1'/"#-.))'/"
Organization
Integrate - Get in touch with new normal

Activate - Start to Use Previously over
lengthened or inaccessible muscles
Attention - Input to Develop Neural

Connections
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

High %
We need to grade to chose where to treat first
RangeSevere Large RED
' "%'!"! "'"!&"%3
)1#-@EDD=MD=LDA-#,.),),."(
@ ,!N= ,!= ,!9A Range &
Moderate Medium YELLOW
)%(!#03)/,)1(,-.,#.#)((/', Partial Skill
Low %
Skill Minimal Small GREEN Goal
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
We use the TMR number to find #1 & #2

80
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
The bigger the number the bigger the issue! 30 to 10 Minimal 40
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:
Total Motion for Tots 8 Step Form 3 Test

On Back Standing
Nam
me
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
2 Lt
Testing
me # morre than onc
ce]
A. Upper Twist B. Side Bend C. Leg Raise D. Arm Raise E. Lower Twist )/HJ'DQJOHG. StandUP4JU
Side (1100) Side (1100) Side (1100) Side (1100) Side (1100) Side (1100) Side (1100) Side (1100)
H. Arm Press Testing
me # morre than onc
ce]
5 Treat
B. SIDE BEND
Sitting Standing Standing On Belly

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
SS
1 Lt Sit on Rt
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
SS
Hard
Side
TMR #
[1-100
0]
RankHard
Side
TMR R#
[1-10
00]
RankHard
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
Hard
Side
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
he Easy Side]] Tre
eatm
he Easy Side]]
o/ho
ow ma
any/ho
ow long? TM
w man
ny/h
how
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
w man
ny/h
how
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.]
Sit Tall &

Hard TMR # What did you do? How many? How Long? TMR # Easy
1st Exercise Side (1100) (1100) Side Home Program (Position Treat Play)
2nd
o/ho
ow ma
any/ho
ow long? TM
w man
ny/h
how
TM o/how
w man
ny/how
w long? TMR # 2nd
o/ho
ow ma
any/ho
ow long? TM
w man
ny/h
how
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 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
o/ho
ow ma
any/ho
ow long? TM
w man
ny/h
how
TM o/how
w man
ny/how
w long? TMR #
LEG
3rd
o/ho
ow ma
any/ho
ow long? TM
w man
ny/h
how
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
3rd Exercise Hard

Side
TMR #
(1100)
What did you do? How many? How Long? TMR #
(1100)
Easy
Side
Home Program (Position Treat Play)
G. SIT-TO-STAND
8 Organize
Cha
ange in
n Ac
ctivitty Lim
mittation
n Cha
ange in
n Ac
ctivitty Lim
mittation
n
& Practice -
Sig
gnature & Plan
Additional Activities: Explore and organize new posture and motion Sensory input easy and hard side.
Sig
gnature & Plan
H. ARM PRESS
Carry Over
Organize & Practice & Infusion
8 Carry Over & Infusion Therapist Signature: Next Visit:
Signature
Copyright 2012 Susan M. Blum
Keep It Simple !
"*"&''%&'%('(%! #'
) !'"(!'"!"('" &3
&&-3-.'- P##(.()' ),.&>-#

-%#&&-,."-/%-1&&)16

#(#'&(.)/-(,!3 ),-.#&#4.#)(.)
.., )/-)(P#(').),
#&#.3.)0&)*-.,(!."#(**)-./,&
'/-&- ),(/,(
#)9'"(#&&3 P##(.*)-./,.&(!."
'/-&--#!(.)1),%
**),./(#.3.)0&)*').),)(.,)&-#(
'),.3*#&0&)*'(.
--.)'/-&-().0#&&0&)*)(.,)&
.)-/**),.
Suck Swallow Breathe Need to fix restriction 1st to Breathe
Impairment can effect physiology - This become priority! (child w/ G tube and hypotonia - shorten in line of tension)
Assessment Simple but Comprehensive

includes All Systems
Important to note issues and improvement in respiration, HR and GI!
as a change in impairment in session note.
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
Side Crunch Side

Crunch Elongate Side
Restricted Elongated
Left Side Level With Lift
Off Balance Left Left

Side Side
Crunches Level Base
What Systems Might Be Affected ? Pre-Treatment Treatment
Chrunches Treatment Post Treatment
How much energy is wasted in the struggle to stay upright

that might be better served for cognitive function?
? #'#.--.)).",'/-&!,)/*->#-/-(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-.#&#4.#)((/-'),,-.,#.#)(-@"#&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
? )(!.,'#'*.) #'')#&#4.#)(;)& <- 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
Neuroplasticity - The Discovery Zone

The child discovers on his own new potential movement Lucien: 22 - 40 Months
Range Pie Charts
Midrange
g New Midrange Di
sco
Zo ve
n er y
HARD HARD
Side Side
EASY SIDE EASY SIDE
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 k d bby Th
Thomas Dalonzo-Baker
D l B k 63
6
Lucien: Crooked training wheels

False Stability by Immobilization
Sacral Sitting Kyphosis/

Scoliosis
Trunk Lateral
Flexion Hip/Knee
Flexion Cx
Limited Trunk
Extension Left Side
Neglect
Torticollis Jan 2008 - CA 22 mo (4 mo)
Sept 2009 - CA 42 mo ( 20 mo)
Lucien at 42 months
Case Study Lucien
Chronological Age v Gross Motor Age Equivalent at Walks, sometimes runs 1/2 mi. to grandmas
Evaluation Stages house
Walks backward and sideward 5-6 feet

CA GM Tosses tennis ball straight with overhand
7 months 3 months
14 months PT
1 month progress Arms relaxed at sides
21-22 months 4 months Kicks a play ball straight 5-6 feet
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
Lucien 2 years post therapy at Mary Massery course

note: paraspinals
The only difference was finding the

Key Restrictions for alignment
&
using his Building Blocks
for motor control
videeo
video
Princess - rapid change with early treatment

Treated with trunk side bend & twists 20 min Lynnia - 5 months of TMR pre and post
Note vertical dimension right side of face!
If we can get a child sooner 7 week old child = Fast Results

Early Correction while still fascia & not yet muscles
Sorrell - CP: Age 28 Months
Post -TMR 1 effect on my practice
Then:
(Received EI since birth)
28 mo. initial evaluation Lucien - Immediate results Monday AM!
Prisoner in own body Focus - Observation skills with higher power
Unable to stand or supinate
forearm Care Plan- No longer hit or miss Spot tx
Severe hip flexion cx Now:
Minimal glut control
5 thousand treatments of children later
100 % TMR as foundation
35 mo follow up visit
Independent feeding & Enhanced application of all other PT methods
Independent ambulation Parent satisfaction, positive experience feedback from
on levels and steps clinicians, consistent improvement in functional outcomes
Body wants to heal itself

Bonus from learning TMR for patients- heal yourself!
My history pre-TMR: Multiple injuries over 30 years
Cascading effect - back brace - orthotics -meniscal tear -knee

brace - patella worn out - ankle surgeries - bilateral custom
AFOs - wrist brace - (cane) - handicapped ID - chronic pain
and sciatica - fibromyalgia
Post-TMR: pain gone
Able to resume athletics & hiking
Several months later no braces
No ceiling on expectations for patients or self! .

Body Healing Itself - What labels are you stuck with and carrying
around? (chondromalacia)-How can you help yourself? (desk chair)
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.
)1(1)(.,)&*)-..,.'(.*)-./,.) Weight shifts deliver sensory input to the brain.

'#(.#()*.#'&-3''.,3;
Body sensations especially pressure on skin and within the spine and joints inform the brain of
changes in body position. The changes in body pressure at the loaded body parts trigger righting reactions
muscle activations on the side opposite a body sway that operate to maintain the upright position.

:
Thousands to millions of weight shifts with righting reactions become programmed as automatic,
predictable muscle activation groupings by the neuromuscular system, and become subconscious and
effective balancing mechanisms.
Cusick, 2012
TheraTogs -Wunzi to maintain 75% of new posture
Maintains upright for perfect practice
LABS:
Use spring to keep same tension while

you kneel, stand and sit
pull with elbows leading
Now practice with partner to move and

keep upper twist
Richards, et al 2012, Flanagan, et al 2009
Aids to Ease in Keeping Position LAB: Consistent Tension and Position

Use mirror to check position
Upper Twist - neutral/ flexed/ extended/
Pretend you are dancingg with child and he is side bent left/ or side bent right
leading LAB: Practice dancing with bungee cord Use videos / mirror to watch alignment
Firm but gentle hold using entire hand.

Cup hand like holding water = sweet spot
no finger tips.
Play-Doh snake one hand goes forward
and the other moves equally backward.
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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?
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
Left Palm cups buttocks Right Palm on ribs,

and Pushes Forward Fingers pointed to
belly button and
Pulls Back
Try as group to crunch tight left side
Gently pick up the slack and hold, waiting for release
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5
LAB:Try End range resistance

Therapeutic Play Rolling Strategic placement of goal:
Left Upper Twist Right Lower Twist What motivates the child to expand range
New Food, Toys, Poster?
Arms to Left Pelvis to Right
Discuss what can we get the child to reach toward.
Using Parents and Your Creativity to Keep it Fun !
Toy Slightly Out of Reach Dangle toy on ball cap

with Right Hand
3
2 Dance instead of push ups
1
Touch Paper With Reach With Foot

Left Foot in a Long Arc
Step 8 Raegan- Therapeutic Play

Upper Twist diagonal crunches to reach toy Home Program / Parent Instruction
Active to Left (falls over to Right - boost Boppy same angle)
Therapeutic Positions: Incorporate into day
24/7 as parent learns to understand childs
body and issues
Therapeutic Releases: TMR motions 4-5 x
day
Therapeutic Play: Use it or lose it, to
Activate New Normal in Daily Routine
EG: Horse Ride to Organize
Help make child alert, and activate / integrate settle into
the new more neutral posture
= Fun / typical developmental skill
Treat as typically developing - just younger
Typical treatment session
Identify what caregiver/ client wants what is your concern today
What was easy, what was hard since last visit
Identify factors limiting progress - less active (car seats, fatigue, illness)
Explain role of less activity = restriction = challenge in movement
Challenges in posture limit energy to learn & may effect all systems
Explain we release shrink wrap to let child learn to move
Test 6 - Hand over hand to feel the 2 hardest

Objectives, Visits and Follow ups Explain relationship between what you felt and what the child is struggling to do
Treat 2
Retest and show parent change in mobility/ posture result
Organize child with proprioceptive input
Use new mobility to facilitate new more neutral (new normal)
Sensory input to hard side
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
::1'&'"'"'"!!3

)1()(.,9&.,&&(!."(#(!
("(,&-5),').),)(.,)&;
)1('),,-#-.(),!,0#.3
("(,&-5),').),)(.,)&;
)1('),.).&').#)(/- ),
#&#..#)(;
)1(/-) ).",,-) .")3
@-/*,#),),#( ,#),("(,&-5),
').),)(.,)&
".#-.",)&) ,)--.,(- ,#(
#&#..#)(;
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)
Position Crunch Whole Motion
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C h 2012 TTotall M
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Therapy TTotall M
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Thomas D
Dalonzo-Baker
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Try with Doll - Crunch in Right Side Bend Contraction into
Adding Resistance to Release Direction of Ease with Gravity Resist for Active Release
y When a child resists motion You can use this

to your advantage? EG: Upper Twist stabilize his hips while he
turns away = intense release. Uncooperative child can be a plus
y The same motion but with a different
ff
position in space, changes release from:
Active Assistt to Active Active Resist?
(EG: upper twist Tilt child in space.)
y Using gravity to slowly lower through motion
through incremental increases in range im-
proves Control (EG: Upper twist as reverse oblique sit ups.)
Dalonzo Baker 91
We learned how each session follow the same sequence:

ASK
Dialogue w/ Caregiver
LISTEN Recheck your symmetry from this morning again

Clinical Observation Sitting and Rotating to side
Zoom Out to note of Functional Limitations, Issues in Other
Systems & List on Patient Profile Side sitting - where is your sternum, umbilicus, sit bones etc.?
Zoom In Focus: Visually Assess Restrictions Does the hard side feel any different in side sit?
Test all 6 - Feel with Hands
Observe Quality of Wt Bearing 7 & 8
RESPOND
Treat 2 , Teach 1
Sensory to Hard Side
Organize (Integrate, Activate, Attention)
Follow Through - Customized Home Program
Demo Child with Torticollis

REMINDER:
MFR My videos show fast motion ( This is because already

know the end range and have worked with children. )
All my assessment & treatment is SLOW!!!
(opt.) Treating Arm Raise w/ MFR to Easy Side
Torticollis
Tape Your Doll
video
LAB and Videos:

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
Pendulum test Knee to elbow test

Physics 101
R SB hard side L SB easy side

For every action
there is..........
Do both sides lengthen equally? Can you touch knee to elbow to
Or does tightness limit range? with equal ease on both sides?
Or is rotation limited?
Onesie Test REPEAT WITH YOUR DOLL
Cant touch
left elbow to
right knee
Right side does

not elongate
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
Compensatory Adaptive Shortening

Similarity between Fascial Bias of Fetus and CCP in Adults
(Pope 2005)
Developmental Influences In Womb
Prenatal Developmental Influences Primary Lie accommodates restrictions of uterine cavity

Head rotate to Left
Fetal Growth Arms and legs curled in opposite directions
Habitus - accommodation to uterine cavity to growth of fetus Rotation along longitudinal axis to compact profile
Lie - relation of long axis to mother (Pope 2005)
Presentation - cephalic or breach
Consider potential impact on final shape of fetus
Impact of pressure or tension increased secretion of connective
tissue fibers organizing along line of tension
(Schultz et al 1996)
THE EQUAL OPPOSITE ACTION What if we treat neck and miss the root?
(Torticollis - a misnomer) really Tortisoma
Child seen for Torticollis -3 months post discharge

How could tort be localized to just neck?
(Had received weekly stretching direct treatment for 4 mo. w/ satisfactory outcome)
+ Early identification - PT referral - parent motivated 4 mo. Rx
+ Mom taught & did positioning (BUT relapse 3 mo. later!)
- Mom taught stretch - apprehensive so wouldnt do as child

cried (TMR - no stretch) "*"&!%''%' !'!!
%!.&'%!'3
- Mom taught sidelying strengthening - couldnt fit into day - 4
kids (TMR - typical strength development in daily routine) )..)'/*)-.)*."#**,)"9(3-,&
-3''.,3#'*.--.,/./,-)0
- Range in extremities noted - but couldnt fully treat (TMR - )*#(=).,/'.)&#.'/-&-
can treat) )))'*&#(#(#&3,)/.#(-
,.#(!J')(.")&-"#&1#."F')(.")&
- Pelvic rotation was tightest area in body - missed the key (%.)0&)*-.,(!."
(TMR - one of 8 motions tested)
- Developmental milestones asymmetrical (cruise one way, roll

one way - pull to stand on 1 leg) (TMR - can treat)
Asymmetry Patterns - Direc

Direction of Ease in Torticollis
The effect of the Pelvic Grade 1 Grade 4 Grade 3 Grade 2
Keystone on the Neck Left
L f
Upperr
20 min Rx Twist
-Target the Root (twists and
sidebend) L TD
L SB R SB
R BU
- Positional Support to
maintain new neutral
Typical C Typical Reverse C S - Bottom Up w/ TD S- Top Down w/ BU
- Taught modified Tummy
Time on chest like typically
developing child
= restriction = bowstring
Corrected w/ One Visit!
(Note she was Level 1 and
identified early)
Asymmetry Patterns - Direction

ction of Ease in Torticollis Asymmetry Patterns - Direc
Direction of Ease in Torticollis
Grade 1 Grade 4 Grade 3 Grade 2 Grade 1 Grade 4 Grade 3 Grade 2
L f
Left L f
Left
Upper Upper
Twist Twist
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
= restriction = bowstring = restriction = bowstring
More discrete restrictions = Tots 2 testing
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
Therapist needs more 1:1 to improve range first. Child

needs to limit sitting which would reinforce undesired
patterns. Attempts to work on sitting reinforce torticollis as
tension pulls into chest & neck.
LAB - Standing with Torticollis LAB - Moving with Torticollis

Try to flex your shoulders
First assume Tort posture #1 LUT/ LSB/ RLT Try transfer kneel to stand
What is impact on symmetry and balance? Try to cruise to the left
What happens to your right foot? Try to crawl - how is left hip flexion?
Is your weight shifted more to one foot? Imagine trying to learn a new skill with UEs like
catch a ball
What if we made Jeremiah get up using his left LE?
Torticollis in Triplets - 3 Different Patterns of Restrictions

LAB: Give yourself Torticollis Who will take longer to correct?
add the Tots 2 restrictions
A B C
The equal opposite actions
(2 & 3 go together - Head tilts toward which is worse)
Grade 2 - S Curve Top Down - Add Drop Left Arm Pit (and flex
thoracic spine on left slightly )
= Right Lower twist + Left Upper Twist & Top Down Side Bend
Grade 3 - S Curve Bottom Up - Drop left buttock (and extend

lumbar spine on right slightly)
= Left Upper Twist + Right Bottom Up Side Bend & Lower Twist
Tortisoma - View severity from sacrum up
AA B C
A B
C
Least Head Tilt Moderate Head Tilt Most Head Tilt

Most Severe Moderate/ Severe Mild Issue
Issue Issue
Asymmetry Patterns - Direction of Ease in Torticollis Degree of

Grade 1 Grade 4 Grade 3 Grade 2 head tilt
Left
did not
Upper
Twist & determine
severity of issue
L TD or
L SB R SB
R BU developmental
implications!
Typical C Typical Reverse C S - BU w/ TD S- TD w/ BU
A
Child C Child A Child B
A B
C
Least Head Tilt

Most Least
Severe
Head Tilt Moderate Head Tilt Most Head Tilt
Copyright (c) Susan Blum PT 2013 Issue
Most Severe Moderate/ Severe Mild
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
l 4 3 (+2) This adds a 2 to the 3 and becomes a

Level 5 (most complex restrictions)
Treated only with neck stretches - base still crooked
Frequent patterns: Head to left more left side bend
Child C - Grade 1 - compatible with development of
equilibrium - easiest to resolve
Categories of Upper Tort
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- L tort - Grade 1

3 min mini. & Curtis - Week 4
#1 LT #2 UT # 3 SB Exploring motion in a new range
Brandon H - Severe Grade 1 - Moving in 10 weeks!
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
Child A - Severe Pattern = Grade 4

Side Bend and LowerTwist to same side
very unstable - cant sit
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
Ask, Listen &

Respond
What does their body
want to do?
Progress Narrows the Field 50 min release

Hand follows the hinge
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
Hand adjusts to hinge as child goes deeper

to get precice level
Combo Treatment - child w/ Reflux
Knee to nose - Keep upright due to reflux (not
supine)
Scoop buttock with knee to nose
Jiggle into a ball
Jiggle into extreme comfort
Tots 2 LAB: Try Tots 2 level Torticollis

Top Down
The equal opposite actions
(2 & 3 go together - Head tilts toward which is worse)
Tort Grade 2 - S Curve Top Down - Add Drop Left Arm Pit (and flex thoracic
Grade 2 spine on left slightly )
= Right Lower twist + Left Upper Twist & Top Down Side Bend
Bottom Up &
Grade 3 Grade 3 - S Curve Bottom Up - Drop left buttock (and extend lumbar
spine on right slightly)
= Left Upper Twist + Right Bottom Up Side Bend & Lower Twist
Extra Dimensions = Grade 5

A Tots 1 level only need to be aware there
At
can be a difference
If you arent sure if its a full C or an S just L TD = 2
treat with other motions and skip side bend EXT

L SB
R BU = 3
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
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
Atypical C Atypical Reverse C Atypical S- Bottom Up Atypical S- Top Down
S curves and anterior flexion/extension

Repeat test for releases need TMR 2 level treatment
side bend with doll
Move your hand

along side from Precise assessment of additional dimensions
arm pit to hip to
o
see if you can seee Using extremities to enhance motion
where tightest on
the same side Each visit assess subtle differences in orientation
layer by layer (hip hike - extension - twists -
lower side bend)
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
Category has the same features as the commonly seen

L UT/ L SB pattern
However there is more upper twist, less side bend PLUS a
Diagonal Extension restriction from left scapula to right hip
pulling right shoulder down and back to depress the left
shoulder and elevate the right shoulder tilting the head to the
right
It is seen less often than other patterns.
Lynnia - Following Childs Lead Mild Complex can have minimal extra dimension and be more of a
Grade 1 than a 5
insert
iin
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
Mild Grade 5 = R tort with Grade 1 due to small extension

that elevates R shoulder enough to tilt head.
Complex as extra dimension, but not as severe in extension =
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
Child B -Head to Right Grade 3 (+ mild Grade 2 = Grade 5)

Often has extra Extension with Bottom Up Side Bend
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
Complex Side Bend Head now almost straight -

needed more First time flexing left hip!
direct PT (Challenge fascial pull right low back)
Therapeutic Play simultaneously teaches skills Therapeutic Position Improves Neck
Severe Bottom Up side bend #1
Caregiver cant do SB - Just Combo twists
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
Left Palm cups buttocks Right Palm on ribs,

and Pushes Forward Fingers pointed to Important to Listen to Child and recheck
belly button and side bends with new motor milestones.
Pulls Back
She developed an S when head upright
Gently pick up the slack and hold, waiting for release
Top Down on Left)
Copyright
C h 2012 Total
T l Motion
M Physical
Ph l Therapy
Th Total
T l Motion
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Th Dalonzo-Baker
D l B k 58
5
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)
Is she ready for discharge?

Is she ready for discharge? Why Not:
Extreme CCP Pattern was so established

This is the default motor pattern that was she used to stabilize
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)
Every time she was stressed

Illness, fatigue, teething, growth, a challenging new motor milestone,
she reverted to locking herself into the CCP pattern
Impossible to go down steps with chest to left and belly to right

Only resolved at age 36 months!
Started as a reverse C - Grade 4 plus extension = Grade 5

Extension resolved but when sitting became an S curve Grade 5
which required more hands on PT
Always need to recheck to see if there is an S later!
Discharged at age 3 when safe and symmetrical on stairs

One year post discharge - All motor skills balanced!
Extension resolved but when sitting became an S
curve Grade 5 which required more hands on PT Tortisoma
Always need to recheck to see if there is an S later!
Impact of Plagio on Chest

Unlatch and correct with L UT
Improved Ventilation
Moving Target Treating of Plagio in Chest
How we treat - Variations of

Position / Release / Play
Easy side in daily routines

Grandma treating to easy side in
The MELT METHOD
daily routines
iincor
ncor
video
vid
deeo
de
deoo vid
vi
video
vide
iide
de
deo
deo
eo
Flexion Restriction Grade 5
Upper Flexion/ plus
Lower Extension Restriction
Affect on digestion, respiration, energy expenditure for

cognitive achievements, Reflux - crunch more!
Lower Tort - Upside down torticollis

Lab: LOWER TORT
Hypomobile Trunk Rotation - Effect on LEs
"*"&'"%'&" #''!
)"# !',&3 L UT/ R LT (Arms at 9 oclock and 3 oclock - lead with
umbilicus at 2 oclock and pull right back pocket back) -
'*..,(--/**,.),.@.),.#)&&#-A What happens to right foot?
-#(!)1(9.)*)1( ,)'.,/(%
L UT/ R LT ( Arms at 12 oclock and 6 oclock - lead with
umbilicus at 10 oclock and pull left back pocket back) -
What happens to right foot?
Uneven pelvic rotation will make transitions uneven

U
TURN BELLY BUTTON TO RIGHT = R LT
Lower Tort Done in with hips extended as issue is seen when standing
Lets look at a lower extremity issue
from a different perspectiv
If the right hip is ER and hypomobile,

midfoot may become hypermobile
Where else might we find significant

hypomobility (restrictions)?
What if we ignore those sites?

Lower Tort Lower Tort
Grade 1
Category Grade 2
Category Grade 3A
Category Grade 3B
Category
Left
Sternum
Rotated Right Hip
Hiked Right
Right Right Pelvis
Pelvis Pelvis Retracted Left Hip
Retracted Retracted Right
Pelvis Hiked
Right Hip
Retracted
Adducted
Right Right Right Right

Foot Foot Foot Foot
Turn Out Turn In Turn Out Turn In
Twins A & B - same trunk issues

Extension Restriction
Affect on gait - often seen with Lower Twist and BU SB
Torticollis & R Toe Out Severe R Toe In &

Asymmetrical Crawl Gait Delay = In More
Left Upper Twist
Grade 5 = Grade 1 ( L C curve + Extension)
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
LAB: Teach Parent UT

Body was imbalanced and now when balanced is
at the gate
Premies or High Arousal
Snuggle into Symmetry How can you show a partner how to
hold the child for comfort?
Consider Arousal level 1st
What kind of cues help them best?
May use gloves or move into direction of ease
with towel or fabric sling rather than touch Try 3 choices to position show parent UT
When we do a motion in 3 different positions we learn it best
(Attermeir, 1984)
What is the Default Position?

What is a Tune Up?
.#&#4#(*,0#)/-*)-./,1"(-.,--6#&&6!,)1."6
(1'#&-.)(->(-,"%-(*,(.1,) P&!- Zero tolerance for tilt
"#&,(('), ,+/(./.-"),.,0#-#.--').),
*..,(-,-)(#-.),.').),*&((#(! )P#-"#(!1#."G9').#)(-'3'(&)(!,/,.#)()
.",*3 ),'),)'*&.,-/&.-8
,(./.#)( ),*)-.#-",!'(!'(.5=),
#(.#P#.#)() ,P&!-(--#..#(!./(/*8
Carreiro, J. E. 2009
Active Play in Sidelying using his UT Direction of Ease
)(-#,7
"*!*##,"'&'%'&!"(%#%&"!
'"""+&0 // /'(&!>'%3
)1'#!".."#-"&*/-*,#),#.#41"#"-*.-)
."-'.")-'#!".')-.(P##&;
"..)/-()1.".1)(<.,#( ),,-.,#.#)(-;;
"..)/-1"(,-.,#.#)(-"0#'*,)0(
"#&"-'),0#&&').#)(;
".'#!".1(/*().(#(!.)/--.""#&
"-'),.3*#& )/(.#)((-*)(.()/-&3
2*&),-"#-(10#&&,(!;
TMR Concept : NAIL IT

Perfect Practice Makes Perfect (Vince Lombardi)
Transition from symmetry to motor control = exaggerated input
Sample Progression Left Side Bend Easy Side Lab:

Part 1 Sit to sidelying with resistance (like Brandon H)
Part 2
= RELEASE + MOTOR LEARNING
Therapeutic Release Play Motor Control

Position Assist to Active - Child Nail It
To Shorten Shorten More Shortens Extreme Work
Left Side
Massive
Fascia Ah Ha!!!! Overflow
Late Start out the Gate

What is their developmental neck Build on what they know!
age?
Circle of Control
How does a typical developing child build
neck strength?
How might we need to modify tummy time
& expectations for sitting?
(6 mo old child w/ 2 mo old neck)
Do our kids learn in a different way than
typically developing kids? -Build on what they
know 10,000 successful reps.
In therapy we create environment to maximize The 6 month old child with tort has a 2 month old neck because he has
just not yet developed strength in the over lengthened antagonists
successful repetitions to catch up.
How might matching of activities with daily routines for more reps/day and
a positive experience of movement for child rather than an exercise
regime or unnatural postures?
Zoom In How might increased application 24/7 accelerate progress?
TMR Tots 2 Concept:

,"*'%'%!*',&%!','!
Avo
Avoid motions using the hard side to prevent retightening
',#,)"#!3"',%!%!',3
Fix restrictions first
)1)-)/,*,-*.#0"(!1"(10#1*.#(.--
Task Analysis - Availability of Motion
"#&,(1")$/-.!).&.-.,.#(."&,(#(!.3*#&
High % 100 0&)*'(.,.",."(,)%("#&;
Missing Ingredent:
Release & RoadBlock
90
RANGE

'*,#-)(#(,-.,#.#)(-6&#'#.#(--.) /&&')#&#.3.)
80
Find Other Option
70
Medium % 0&)*(2*&),').),)(.,)&(2*)-.)
60
RANGE -(-),3#(*/.8
Release & Modify Detour 50
& SKILL
40
)1(1P#&&#(."').),(-(-),3&))*")&-.)
Low % 30 -/**&'(.1".1-'#--;
Minimal GO 20
SKILL
)1(1*.-/**),..)1),%#(."!**,)*,#.
10
0
0,.#&*)-./,-1#.".")'*)((.-."."#&(
Copyright
C h 2011 Total
T l Motion
M Physical
Ph l Therapy
Th Total
T l Motion
M Release
R l and
d k d by
b Thomas
Th Dalonzo-Baker
D l B k )(.,)&;
Children with Hypotonia Review in Fragile Child

Caress - Ask,, Listen,, Respond
p
Lower Threshold for Imbalance to
Control Function
(Less strength = Less reserves to compensate)
Lacking strength to compensate and be upright,
Need to be EXTRA symmetrical to for OP TIMAL

Biomechanical efficiency
Might they need to be even lower in green zone?

High %
Severe
Medium %
Moderate
Low %
Minimal Goal
Support to maintain new normal
Hypotonia = More restrictions - Need stacked with symmetry "*&'&"!#'##'"',#&
"#%'&3

,.#("#,/-#(!E9F').#)(- ),..,
*)-#.#)(#(!1#."P#(').),),-*"-%#&&-
,.)('.1#."0( #&#..#)()
.,(-#.#)(-)(-3-#0)##(!,-.,#.#)(-
-%(&3-#-.)0)#,-.,#.#)(-()((.
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LESS MARGIN FOR ERROR
-) *,(."()/.-( ),'- ),
,!#0,-(#(!)*.#)(-@&(!/!,,#,-A
-1#.").",)(*.-7

My teachers!
Additional Thoughts
Long Lever Arm Leg Lift hamstrings limited range

Improved with 8 mo Twists = The Power of Indirect Treatment
Cant do all 6?
You can ALWAYS do something even if not all FAB 6
Even just positioning the child is getting more than

seeing you an hour a week
Tots 2 - Needed fine tuning with more dimensions
Special Situations Fine tune to get to the key
Child sleeping - Terrific!
Child too Active
Child Fragile
Child Stiff - Crystal 15 min to assess side bend
Child with Autistic Spectrum or Severe Sensory

Avoidance no touch / no auditory tolerated
Parent with Intellectual Disability
Daycare- may be only therapeutic positioning but if 24/7

you are still ahead of the game
Look deeper - Refine motion - EG: up-out-in
What to tell parents & Peers
It isnt new so, dont say New

Ask peers for 2 weeks to do their other techniques to
Can say I wonder how he will do with a assess childs response
a different way of handling to get range
that kids find more comfortable Are you willing to give it a try?
Lets Experiment
My mission
Clinical Expertise
Best Patient Values

Research &
EBP
Evidence Preferences
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

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A Taste of Tots for Torticollis

Total Motion Release for Tots

(demonstrating)individual clinical expertise

(Sackett et al 1996, Evidence based medicine: what it

What does their body

Autonomic Arousal Level - Regulation

Albert Einstein Lymphatic Fluid Balance - Delayed Healing

Innovation: Tom developed concept based on established

What is the dog doing ?

Stecco 2007, 2008

Thought for the day:

You are invited to

Where lacking STRENGTH & CONTROL?

First look at RESTRICTION

Now first ask:

Where is MOTION RESTRICTED?

The restriction was limiting ACCESS to the

How is TMR different ? How is TMR different ?

A1. For children with torticollis

Balance the Body in Symmetrical Alignment

TMR is what we already do as pediatric PTs

Weve used for a long time with adults

We just havent had a way to teach parents or caregivers to so

Engage Unlatching principles

Indirect technique to release restriction by encouraging motion in direction of ease.

Shift in Focus - Simple Care Plan

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 #',.(!!(&'" #"*% &'" "*"&' %%" &'%"&3

Stretch does not have clinically important effects on joint

What about shortening for patients with

Feel restrictions Left Side Shortened / Shoulders to Left

1. Tuck shirt at front/ center.

2. Stand and tuck in shirt on the left side

1) Health Condition (dx): 1) Health Condition (dx): CP - BLEs R UE?

Wheres the restriction?

5) Contextual Factors: 5) Contextual Factors:

Copyright 2012 Susan M. Blum Copyright 2012 Susan M. Blum

TMR Tots 8 Step Form

Bungee Cords = Restriction in Motion

"*"*)"#' &, '%,3

Find soft tissue restrictions limiting range (TAPE)

Identify and describe as precisely as possible on

Consider how one small restriction in a

Age: 3 mo referred tp EI - Dx at well check up:

Video of mobility in trunk

We now measured w/ photos - now supine (Rahlin, et al. 2010)

All my assessment & treatment is SLOW!!!

Checking all motions - Identifying tightest spot in chest

Ask, Listen &

(We grade how limited it is to the right (in direction of barrier)

The Green tissues are extensible like Silly Putty

Direct Technique = Treatment into Direction of Barrier R UT

We move into the direction of ease (no chance of Pain!)

We use the rest of the body to indirectly correct the restriction

We can indirectly shorten a restriction by using contralateral

EASY SIDE EASY SIDE

Match the Motion

Total Motion for Tots 8 Step Form

#1 Listen & Respond 2. What ACTIVITY is Limited Related to Restriction?

Ask, Listen & Respond

)1 & .) ,-.,#.#)(-)(-& #(."#-*)-./,

LAB: Feel some additional restrictions on self

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"%!%'"!"&7" "%'= ""%%&2 ,"!>'''%'!'"%'"&'&'%'!0

<'##%"&&#%")&,&' '7"7 '&' "&'(%%!'!"% '"!"!$( !(

#',.(!!(&'" #"% &'" ""&'%%" &'%"&3

"")"#' &, '%,3

)1 & .) ,-.,#.#)(-)(-& #(."#-*)-./,

Side sit on floor arch of foot on knee '&'&,&3

Structural Imbalance "*&%!''!"&'"!&3

Poor/ Distorted Foundation to Develop Motor Control L-#').#)(->&)!#&6 P##(.G'#(/.----'(.

"!$(,!',' "&'%&'%' ?-.,)(%3').#)(**,1#-.

What if one side is limited in range but the @#!".0-8 .A