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The Effects of Total Motion Release Tots and Teens to Resolve Myofascial Restrictions
Restoring Range of Motion to Improve Gross Motor Function and Achieve Symmetrical
Posture in a Child with Cerebral Palsy: A Case Report
Author: Allison R. Wierda

Research Advisor: Karen E. H. Grossnickle, PT, DHSc
Doctoral Program in Physical Therapy

Central Michigan University
Mount Pleasant, Michigan
Date (Month, Day, Year)
Submitted to the Faculty of the
Doctoral Program in Physical Therapy at
Central Michigan University
In partial fulfillment of the requirements of the
Doctorate of Physical Therapy
Accepted by the Faculty Research Advisor
(Electronic or Written Signature here)
Karen E. H. Grossnickle, PT, DHSc
Date of Approval:
ABSTRACT
Background and Purpose
Cerebral Palsy (CP) is a neurological condition which can impact mobility. Limited
mobility has been known to cause muscle contraction and shortening leading to myofascial
restrictions. Total Motion Release Tots & Teens (TMR-TNT) is a novel approach that has the
potential to effectively release myofascial restrictions, restore range of motion (ROM), aid in
gross motor development, and achieve a more symmetrical posture in a child with CP.
Case Description
An 11-month-old male was first seen by Early On physical therapist for gross motor
development. Upon initial observation the patient lacked purposeful functional movements of
both his upper and lower extremities. Clinical findings upon examination found a significant
delay in gross motor function and neurological function, restrictions in all four body motions
assessed, and an asymmetrical supine resting posture. Intervention consisted of two different
TMR-TNT static treatment holds with instructions to caregivers to execute holds daily. The
Peabody Developmental Motor Scales-Second Edition (PDMS-2), TMR-TNT screening
assessment and myofascial restriction grading scale, and photo documentation of supine resting
posture were used to track patient progress.
Outcomes
The use of the two different TMR-TNT treatment holds resulted in decreased myofascial
restrictions, an increase in total PDMS-2 gross motor score, and more symmetrical supine resting
posture. The myofascial restriction grading scale showed minimal, but increased movement, in
all four body motions screened. Between week 1 and week 7 all body motions had a at least a
10% decrease at some point and were symmetrical, with the exception of one body motion with
no change of 90%. The PDMS-2 gross motor score at week 7 increased from 15 points at
baseline to 18 points. By week 7, the patient also showed significant improvements in upper
extremity tone and an overall more neutral and relaxed symmetrical posture while in a supine.
Discussion
In this case report, TMR-TNT was the main treatment interventions over the course of 7
weeks. The results and photo documentation demonstrated positive improvements in gross motor
function and supine resting posture. Clinicians treating patients who display a similar
presentation may consider TMR-TNT as a possible treatment option.

Background and Purpose
Cerebral palsy (CP) is a non-progressive neurological condition which is caused by injury
to the developing fetal or infant brain and is the most common physical disability in children.1,2
In pre-term babies, between 22 to 27 weeks of gestation, the prevalence of CP significantly
increases with the diagnosis occurring in approximately 146 per 1000 births.3 Cerebral palsy is
characterized by varying impairments in motor function which can cause activity limitations.1
Other impairments associated with CP may include those involved with cognition,
communication, sensation, perception, and behavior. 4
Children with CP present with primary impairments of body function and structure that
can lead to secondary impairments.5 The primary impairments of CP are directly linked to the
injury of the developing brain and may include abnormal muscle tone, postural instability, and
difficulties with motor coordination.6 Secondary impairments can develop as a result of the
primary impairments as the child ages. Secondary impairments may include body malignment,
decreased endurance, joint immobility, decreased muscle strength, or restricted range of motion
(ROM).4,6
Since CP impairs the neuromuscular and musculoskeletal systems, it often leads to
increased sedentary behavior compared to typically developing children.2 With limited activity,
adhesions in the fibrous connective tissue, fascia, can cause muscle to contract and shorten
leading to myofascial restrictions.7 These myofascial restrictions can potentially restrict an
individual’s range of motion (ROM).7
Prevention of secondary impairments, such as impaired ROM, is important for the overall
health and motor function of children with CP so the child can increase independence and
achieve more developmental milestones.4 According to research, 60% of children with CP have
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ROM restrictions in their lower and/or upper extremities.6 It was noted that as ROM limitations
increase, the functional motor ability of the child decreases.6 This inverse relationship is seen in
children with CP, specifically between 2 and 14 years of age.6 Through professional intervention
such as physical therapy, secondary impairments can be preventable, and improvements may be
exhibited in gross motor, fine motor, and participation outcomes.5
Research supports the hypothesis that during early childhood there is a sensitive period
for the development of gross-motor function in children with CP; with the greatest increase in
gross-motor development occurring between 1.5 to 5 years of age.4,5 In a longitudinal study of
656 children with CP, it was found that the rate of achievement of gross-motor abilities is
greatest during early childhood and begins to level at about 5 years of age.4 Therefore,
interventions are more effective when provided during early childhood because this is a sensitive
period for gross-motor development.4
Many interventions have been examined in the treatment of restricted ROM in children
with CP however, the definitive treatment remains unclear. Non-invasive treatment options that
have been used to target restricted ROM in children with CP have included biofeedback, casting,
neurodevelopmental therapy, orthotics (splints), and passive stretching.8,9 Documented research
has found that biofeedback improves muscle activation and active ROM, however, the quality of
the evidence is low.8 Plaster casts have shown improved passive ROM in the lower extremities,
but there is insufficient evidence for the upper extremities.8 Neurodevelopmental therapy has
shown no superior gains in ROM compared to other treatments and it was noted that ROM
improvements within one session did not carry over. 8 Orthotics (splints), such as ankle foot
orthotics (AFOs), have had positive effects on ankle ROM but the quality of the evidence is
low.8 In another study, it was found that a 16-week stretching program of the hamstring muscles
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did not result in a significant difference in passive popliteal angle or active popliteal angle
between groups.9 Therefore, the optimal treatment option for restricted ROM in a child with CP
continues to remain unclear.
Total Motion Release Tots and Teens (TMR-TNT) is a manual therapy technique that is
used to release myofascial restrictions to help increase a patient’s available ROM and functional
movement.10,11,12 The TMR-TNT technique is based off the strain-counterstain method.11,12
Strain-counterstain is a manual therapy technique that was developed in 1955 by
osteopathic physician, Lawrence Jones, that can be used to treat myofascial restrictions.13 It uses
body positioning towards the position of comfort (towards body motion of least restriction) to
help release tissue restriction by relaxing the muscle spindles.13 Instead of forcing a contracted
muscle toward its restricted barrier, the position of comfort allows the muscle to continue to
shorten until it relaxes normally.14 The stretch reflex is responsible for regulating the length of a
muscle by automatically increasing contractility, as long as the stretch is within physiological
limits. 15 When an already shortened muscle is stretched, it will induce further contraction as well
as increase muscle tone via the stretch reflex. 16
The only way to feel for myofascial restrictions is through palpation which does not have
a measurement tool. The use of the examiner’s hands is the best method to seek out and grade
the patient’s restrictions. Therefore, the TMR-TNT screening assessment is a highly subjective
instrument as the examiner has to feel for myofascial restrictions by assessing body motions
bilaterally and then interpret the findings.12 The examiner interprets the severity of myofascial
restrictions displayed in the body motion by using the myofascial restriction grading scale. Once
the restrictions are identified, a treatment plan can be designed specifically for the patient.
Identified body motions of the trunk, with the least restriction, determine the treatment position.
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Treatment is then executed by performing a passive static hold at the end of the patient’s
available body motion range.17 Static holds need to be sustained for at least 90 seconds, allowing
for the muscle spindles to slow down afferent firing frequency.18 A slow return to neutral
position avoids muscle spasm.18
TMR-TNT is a favorable treatment as it offers unique features that lead to parent
satisfaction. The unique features include a focused plan of care geared towards getting to the root
of the problem and meeting the patient’s needs, caregiver empowerment by learning the
technique allowing treatment to be executed daily and placing the patient in their position of
comfort eliminating the possibility of a painful stretch.12
Documented research on TMR-TNT as a treatment intervention to resolve myofascial
restrictions and restore ROM is scarce; a thorough search of relevant literature of TMR-TNT for
pediatric patients yielded no related articles. There is documented research on standard total
motion release (TMR), which uses the same strain counterstain method as TMR-TNT.19
However, TMR is predominately used with typically developing adults because the treatment is
executed independently by the patient with active motion.19
In one study, a TMR warm-up was compared with a traditional overhead athlete warm-up
to determine the immediate effects on ROM in overhead athletes.17 It was determined that the
athletes in the TMR group demonstrated significantly increased ROM compared to the
traditional warm-up group. 17 The TMR group was also deemed more efficient since results were
seen after only 7 minutes, compared to the traditional warm-up group of 25 minutes.17 In a case
report involving a high-school cheerleader with a frozen shoulder, TMR was the chosen
treatment intervention while utilizing breathing treatments.11 The patient in this report improved
shoulder ROM and shoulder function in 16 treatment visits over the course of 6 weeks.11
4
Other manual therapy techniques, such as myofascial release, have been implemented to
decrease myofascial restriction. However, documented research on the use of it for children with
CP is limited. There was one study that reported on six case reports regarding the effects of
myofascial release in children with CP. The results indicated that after 24 weeks of myofascial
release, patients had positive observed outcomes including increased body symmetry and
ROM.20 In another study, myofascial release was found to improve motor function in children
with moderate to severe CP.21
Further research is needed to explore the use of TMR-TNT as an intervention for
pediatric patients with CP. Therefore, the purpose of this case report was to describe the effects
of TMR-TNT as a treatment method for myofascial restrictions to restore ROM, progress motor
development, and achieve a symmetrical supine resting posture in a child with CP. The
myofascial restriction grading scale, PDMS-2, and photo documentation were used to document
patient changes during the TMR-TNT intervention period.
Prior to preparing this report, assent was obtained from the patient and consent was
obtained from the patient’s mother to proceed. All information contained in this case report
meets the Health Insurance Portability Accountability Act (HIPAA) requirements of the clinical
agency for disclosure of protected health information. This case report was completed under the
direction of the Department of Physical Therapy and with the oversight of the College of
Graduate Studies of Central Michigan University.
Case Description
Patient History and Systems Review
The patient is a male born prematurely. He was born by normal spontaneous vaginal
delivery at 26 weeks of gestation with a birth weight of 2 lb. 1 oz. At the time of birth
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appearance, pulse, grimace, activity, and respiration (APGAR) scores were 4 & 7 & 7 (at 1 & 5
& 10 min).22 His present chronological age is 1 year 2-months and his adjusted age is 11 months.
He was diagnosed with CP by a neurodevelopmental pediatrician and has multiple medical
involvements. The patient’s CP presents as quadriplegic, meaning all four extremities are
functionally compromised. He displays low tone in his trunk and neck, central hypotonia.
Simultaneously, he exhibits high tone, hypertonia, in all 4 extremities with more tone being
present in his upper extremities compared to his lower extremities.
At birth the patient had chronic lung disease of prematurity. Early in his hospital course
he was on both conventional ventilation and high-frequency oscillating ventilation. He came off
positive-pressure assistance 3 months after birth and supplemental oxygen 4 months after birth.
He went back on supplemental oxygen when he was diagnosed with influenza A 10 days after
removal of supplemental oxygen.
Three days after birth, the patient developed an acute kidney injury. One week, after birth
the patient was diagnosed with necrotizing enterocolitis and was made nothing by mouth (NPO).
One week after birth, his course was further complicated by a diagnosis of Escherichia coli (E.
coli) meningitis and ventriculitis on the same day. Exploratory laparotomy and gastrostomy tube
(G-tube) placement occurred 1 month after birth and resulted in a 10 cm removal of his bowel.
The patient had multiple episodes of feeding intolerance throughout his course of stay. The
patient currently still has his G-tube, but only uses it for feedings at night. All other feedings are
done by bottle.
The patient also experienced left renal hydronephrosis 1 month after birth confirmed by
abdominal ultrasound. He was diagnosed with retinopathy of prematurity 1 month after birth and
endured an 8-hour laser photocoagulation 3 months later. Five months after birth the patient
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experienced another surgery for bilateral inguinal herniorrhaphy as well as bilateral orchiopexy.
Medical imaging also showed skeletal abnormalities including scoliosis and high riding clavicles
“handlebar clavicles”. The patient spent a total of 6.5 months in the neonatal intensive care unit
(NICU).
The patient lives in a home with attentive, supportive family. The patient’s mother and
farther both reside in the home and are the patient’s primary caregivers. The patient’s
grandmother also provides care weekly while the mother and father are at work. The patient was
referred to Early On physical therapy by his NICU physician: “Early On is Michigan's system for
helping infants and toddlers, birth to age 3 and their families who have developmental delays or
are at risk for delays due to certain health conditions. It's designed to help families find the
social, health, and educational services that will promote the development of their infants and
toddlers with special needs.”23 The patient started Early On physical therapy 11 months after
birth, however, initial visit was via tele-health due to coronavirus 2019 (COVID-19). The
patient’s physical therapy continued via tele-health for 2 months before being seen by the
physical therapist in person. The patient is seen in his home by Early On physical therapist bi-
weekly for 60 minutes.
The patient also receives home health physical therapy bi-weekly through a different
agency, opposite weeks of Early On physical therapy, for 60 minutes. The patient has an
occupational therapist that also does weekly home visits for 60 minutes. The patient was re-
evaluated by physical therapist and student physical therapist when in person home visits
commenced, 2 months after initial tele-health visit. At this time the patient’s chronological age
was 13 months old. On this day baseline data was collected that was used in this case report. The
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mother of the patient stated her physical therapy goals for him is to have increased functional
movement and independence.
Clinical Impression #1
After reviewing the patient’s history and systems review, it was determined that the
patient would be a good candidate for the TMR-TNT intervention. The patient spent 6.5 months
in the NICU which may have resulted in lack of mobility due to prolonged static positioning.
Pre-term infants typically have inadequate muscle tone and remain in restrictive body positions
in the NICU.24 In these restrictive positions the body experiences prolonged joint compressions,
with limited mechanoreceptor activation, leading to skeletal deformation, adaptive muscle
shortening, and restricted joint mobility.24 All the aforementioned impairments associated with
pre-term infants can lead to abnormal movement patterns limiting the patient to independently
explore their environment.12,25
According to research, children diagnosed with CP live a significantly more sedentary
lifestyle which leads to weakness, atrophy, and shortening of the muscles.26 Muscle weakness
can lock the child into dominant movement choices which are easier for them to move in and
avoiding those movements that are more challenging.12
The plan for the objective examination was to use the Peabody Developmental Motor
Scale – Second Edition (PDMS-2) to establish a baseline for the patient’s current gross motor
status.27 The Hammersmith Infant Neurological Examination (HINE) was also deemed
appropriate to help identify the patient’s neurological function.28,29,30
The TMR-TNT screening assessment would be used to identify myofascial restrictions in
four body motions assessed which are potentially limiting ROM and further delaying gross
motor development. A thorough examination of gross motor development, utilizing PDMS-2,
8
was considered necessary to determine the patient’s baseline so changes in gross motor function
could be tracked. The TMR-TNT screening assessment would be used to identify myofascial
restrictions in the body motions and myofascial restriction grading scale would be used to
interpret them so changes could be measured throughout the progression of treatment. The
patient’s supine resting posture would be documented through a series of patient photos to
visually track increased symmetry of supine resting posture.
Examination
The patient qualified for Early On physical therapy services based on his established
condition of CP and was first seen for a physical therapy screen in his home accompanied by his
attentive mother.
Observation. The patient was very engaged with his eyes, but lacked purposeful movement of
upper extremities, lower extremities, and trunk. The patient was initially observed in a supine
position on his play mat. His resting posture was observed as high flexed tone in bilateral upper
extremities, increased left lateral trunk flexion, and mild flexor tone in lower extremities with
greater tone on right compared to left. His lower extremities also rested in extreme external
rotation (Figure 1). His supine resting posture was asymmetrical and lack of functional
movements appeared to be due to limited ROM. He displayed limited trunk rotation in supine as
he was unable to independently roll to either side. When presented with a toy at midline, he was
unable to move bilateral upper extremities to the toy indicating limited upper extremity ROM.
He appeared to have restricted neck rotation as he proceeded to track his toy only with his eyes
instead of rotating his neck when the toy was moved greater than 45 degrees left or right from
midline. In prone, the patient was unable to lift his head, extend his neck or trunk, or weight bear
in a prone on elbows position. In sitting the patient demonstrated central hypotonia as noted by
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excessive trunk flexion and he required maximum assistance at trunk to remain upright. He sat
with a posterior pelvic tilt and was unable to sustain his head held in upright and midline.
Mobility Assessment. In supine, when assisted with rolling, the patient did not display dissociated
movements in head, trunk, and pelvis. He rolled as one unit going both directions. When pulling
to sit, the patient required maximum assistance at hands to assume an upright sitting position but
was able to keep his head in midline with his chin tucked. The patient did appear strained during
pull to sit, as noted by his facial expression.
Peabody Developmental Motor Scale-2nd Edition. The PDMS-2 is a standardized evaluation tool
that can be used over time to measure motor skills and development for children with CP from
birth through 6 years of age.27,31 The PDMS-2 measures both gross motor and fine motor;
however, only gross motor was evaluated for this patient. The PDMS-2 is appropriate for
investigating the motor progress of children with CP because it incorporates both quantitative
and qualitative rating criteria.31
The patient’s gross motor (reflexes, stationary, locomotion) skills were assessed using the
PDMS-2. For typically developing children, reflexes are not assessed on children past 11 months
due to integration, however, because of the prematurity and nature of multiple medical
involvements, reflexes were deemed appropriate to assess. A student physical therapist
completed the gross motor portion of PDMS-2 during his initial physical screen.
The PDMS-2 includes six subtests, testing gross motor and fine motor, including
reflexes, stationary, locomotion, object manipulation, grasping, and visual motor integration. The
testing starts with an age-level entry for each section tested and each item-level is scored from 0-
2. This scoring system determines the ability to perform the specific activity. Three 2’s need to
be obtained in a row in order to establish the basal level, commencing until a ceiling is reached
10
with three 0’s in a row.31 Due to the patient’s low motor function, three 2’s were not obtained in
a row for reflexes or locomotion and raw scores were reported for the three subsets to track
progress. This may impact the validity and reliability of the measure.
The following statistical metrics are based on data from children with mild to severe CP
and between the ages of 27 and 64 months. The test-retest reliability for raw scores is excellent
for gross motor with an ICC = 0.996 (P<.0001).31 The standard error of measurement (SEM) for
raw scores for gross motor was 3.0.31 The Guyatt responsiveness index-responsiveness (GRI-R)
values for gross motor percentage composite was 1.7 indicating small change.31 Effect size for
each composite was 0.2 indicating small change.31 Standardized response mean (SRM) values of
PDMS-2 percentage scores for gross motor were 0.9 indicating a small change.31 The Guyatt
responsiveness index-sensitivity (GRI-S) for gross motor percentage composite was 1.6.31 The
minimally clinically important difference on the PDMS-2 for children with intellectual
disabilities is 8.39.32 There is no documented minimally clinically important difference for the
PDMS-2 related to children with CP.
The patient’s gross motor composite scores were calculated by summing the raw scores
of the three subtests and percentage scores were calculated by dividing subtest raw score by max
total for that subtest and multiplying by 100. The percentage scores for each subtest were
summed and divided by 3 to retrieve gross motor percentage score. The baseline results of the
PDMS-2 at initial examination are shown in Table 1.
Hammersmith Infant Neurological Examination. The HINE was developed to assess
neurological function in infants between 2 and 24 months of age.29 The HINE is composed of
three parts: a neurological exam, developmental milestones, and behavior; however, the only part
that is scored is the neurological examination.28
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The neurological exam includes 26 items divided into five domains: cranial nerve
function, posture, quality and quantity of movements, muscle tone, and reflexes and reactions. 28
Each item is scored from 0-3, with the maximum score for any one item equaling 3.28 The
individual scores can be summed together to achieve a global score. The global score can range
from 0 to 78 with the higher the score indicating better neurological performance.28
It has been documented that the HINE has good interobserver reliability, even in testers
who are inexperienced.29 There is no documented data regarding validity of the HINE. However,
it has been found that the HINE is the most predictive neurological exam for CP.30 It is
recommended that the HINE should be completed within the first year of life when possible
neurological problems may be of concern.30 Utilizing the HINE may increase diagnostic
accuracy but does not typically result in an overdiagnosis.30
If an infant receives a global score of <57 at 3 months, it is 96% predictive that the child
has CP with a sensitivity of 96% and specificity of 87%.29 The patient scored the following on
each of the five domains: cranial nerve function (12/15), posture (5/18), movements (1/6),
muscle tone (16/24), and reflexes and reactions (3/15). The results of the patient’s HINE scores
at initial examination are displayed in Table 2 with further explanation. The patient scored a
global score of 37. A global score of <40 is in association with severe CP and severe motor
impairments with the inability to sit independently at 2 years of age.29
Total Motion Release-Tots and Teens screening assessment. The patient’s myofascial tightness,
potentially limiting ROM, was identified utilizing TMR-TNT screening assessment. During the
screen, four body motions were assessed bilaterally and passively: trunk rotation, lateral trunk
flexion, upper extremity shoulder flexion, and lower extremity hip flexion.
12
The patient’s trunk rotation was assessed with him in sitting. The student physical
therapist placed hands under the patient’s axilla to assess rotation restrictions bilaterally (Figure
2). This motion assessment is referred to as upper twist (UT). Lateral trunk flexion was assessed
with the student physical therapist standing, holding patient, with arms crossed at patient’s chest
and pelvis. The child’s chest was held in place while the student physical therapist assessed trunk
side-bending restrictions by moving the patient’s pelvis towards their opposite shoulder of side
being assessed (Figure 3). The motion assessment is referred to as side-bending bottom up (SB-
BU). Shoulder flexion was assessed while the patient was lying in supine on a flat, stable
surface. Shoulder flexion was assessed one upper extremity at a time. The student physical
therapist held the patient’s hand as she passively moved the patient’s arm into shoulder flexion
(Figure 4). The process was repeated on the contralateral extremity. This motion assessment is
referred to as arm raise (AR). Hip flexion was assessed while the patient was lying in supine on a
flat, stable surface. Hip flexion was assessed one lower extremity at a time. The student physical
therapist used one hand to position the patient’s lower extremity into neutral and then stabilized
the patient’s hip on the side being assessed with their other hand. The lower extremity was then
passively moved into hip flexion to identify restrictions (Figure 5). The process was repeated on
the contralateral extremity. This motion assessment is referred to as leg raise (LR).
The myofascial restriction grading scale then allows the examiner to interpret the
restrictions felt during the TMR-TNT screening assessment. The grading scale is a subjective
interpretation the of myofascial restrictions the examiner feels when passively moving the child
through the four body motions. The examiner categorizes the restriction felt using a 3-color
system and percent grading of 0% to 100% (Figure 6). One of the four motions are assessed
bilaterally and passively by the examiner. The examiner then feels for which side, left or right,
13
has more myofascial restriction. The restriction is then graded with a color: red (high restriction),
yellow (medium restriction), green (low restriction) and a percent is then given to determine the
difference in restrictions between left and right sides. The higher the percent indicates greater
restriction and the lower the percent indicates less restriction. The colors closest to green and the
percent scores closest to zero would identify the patient’s least restriction and would be the
position that treatment should be completed in.
There is no documented data regarding validity and reliability for TMR-TNT screening
assessment or myofascial restriction grading scale. The screen and grading scale are highly
subjective as the results are based off of the examiner’s interpretation of myofascial restrictions
felt on the patient through palpation of body motions. The results are then quantified by the color
and percent grading system. Therefore, TMR-TNT screening assessment could be presumed to
have face validity. The TMR-TNT screening assessment and myofascial restriction grading scale
seems to reflect the patient’s myofascial restrictions leading to limited ROM, but it does not
depend on published evidence.33 It could be assumed that the TMR-TNT screening assessment
and myofascial restriction grading scale has good intra-rater reliability. Although they are
subjective, if performed by the same examiner it should be consistent. The only way to feel for
myofascial restrictions is through palpation which does not have a measurement tool. The use of
the examiner’s hands is the best method to seek out and grade the patient’s restrictions.
The TMR-TNT initial screening assessment resulted in marked restriction when the
following body motions were assessed: right UT, right SB-BU, left AR, and right LR as noted by
the color and percent grading system (Table 3). The motions of marked restriction indicate where
the patient’s tissues are shortened and are being stretched. Although four motions were assessed,
the patient’s position of comfort and treatment position is determined only by the UT and SB-
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BU. The AR and LR motion are important for tracking progress of treatment but are not included
in treatment positioning. Treatment positioning was executed by the student physical therapist
and caregivers using a static hold in the patient position of left UT and left SB-BU.
Clinical Impression #2
Based on the patient’s history, physical examination, skilled observations, and outcomes
on the PDMS-2 and TMR-TNT screen assessment, it is hypothesized that the patient has
myofascial restrictions that have limited his available ROM. The patient’s limited available
ROM is possibly further contributing to his inability to complete gross motor skills as assessed
by PDMS-2. The patient spent a significant period of time with limited mobility while in the
NICU and also has a diagnosis of CP which impacts the child’s ability to move. The patient’s
neurological and medical factors are known to be associated with muscle weakness, limiting the
child’s movement choices to the ones which are easiest to access. The patient’s lack of mobility
is thought to have led to myofascial restrictions and tissue shortening as determined through the
TMR-TNT screening assessment and observations of patient’s supine asymmetrical resting
posture.
TMR-TNT was deemed an ideal treatment paradigm to address the patient’s myofascial
restrictions that have limited his ROM and therefore, contributed to further impairment of
functional movement and gross motor delay. TMR-TNT may be an important intervention when
resolving myofascial restrictions to restore ROM in a child with CP because it is an indirect
treatment: therefore, the chances of irritability are low, fostering patient satisfaction. 11
Using the TMR-TNT screening assessment, the student physical therapist was able to
identify body motions where the patient had severe myofascial restriction when compared
bilaterally. The patient had marked restriction with the following body motions: right UT, right
15
SB-BU, left AR, and right LR (Table 3). Based on the results of the TMR-TNT screening
assessment, initial treatment was developed.
The successfulness of TMR-TNT as an intervention was measured using the baseline
results of the PDMS-2, TMR-TNT screening assessment, and photo representation of resting
supine posture. The TMR-TNT intervention would be considered successful, when the patient
displayed increased gross motor function as measured by the PDMS-2, the myofascial restriction
grading scale resulted in lower percent scores indicating decreased myofascial restrictions, and
resting supine posture assessed via skilled observation with photo documentation was
symmetrical with arms resting at sides.
Intervention
TMR-TNT treatment was developed based on the patient’s body motions which were
assessed by the student physical therapist using the TMR-TNT screening assessment and then
interpreted by the student physical therapist using the myofascial restriction grading scale. The
TMR-TNT screening assessment provided insight as to which body motions displayed the least
myofascial restrictions and therefore, the patient’s position of comfort. The patient’s position of
comfort was found to be left SB-BU and left UT. The patient was held by the student physical
therapist or caregivers using passive static holds at the end of available body motion range in left
SB-BU and left UT. This was determined by the student physical therapist to be the optimal
initial TMR-TNT technique based off of the patient’s age, medical factors, and cognition.
During day 1 of treatment, the student physical therapist held the child in her arms and on
her lap as she sat on the floor. The patient was first passively SB-BU to the left to the end of
patient’s available body motion range. The physical therapist then assisted left UT position by
16
passively moving the patient’s right upper extremity across body to induce trunk rotation, while
the patient was in the left SB-BU position (Figure 7).
The patient was held in this position for 5 minutes. As time elapsed, the patient began to
have increased muscle relaxation, therefore, increasing the available body motion range in this
position. The student physical therapist continued to move the patient into his new available
body motion range, throughout the 5-minute time frame, as the patient further relaxed.
After 5 min, the student physical therapist slowly brought the patient out of the initial
position. The four patient body motions were re-assessed bilaterally pre- and post- each
treatment session by the student physical therapist. This allowed the student physical therapist to
determine if patient’s body motions impacted by treatment daily.
During day 1 of TMR-TNT intervention, the student physical therapist instructed the
patient’s mother how to complete the TMR-TNT technique with her son. Upon first explaining
the technique to the patient’s mother, a soft bodied baby doll with electrical tape strategically
placed was used as a visual to show the mother where her son’s shortened tissues were located,
how this pulls him into his position of comfort, and how it limits his ROM. The student physical
therapist explained to the mother that the goal of positioning with TMR-TNT is to wrinkle the
tape on the baby doll which allows the tissue to relax. The analogy of a knot in a rope was used
to visualize what was happening in the shortened tissue. She was told to imagine a rope with a
knot in the middle, if you pull on both ends the knot gets tighter and if you push the rope towards
the knot it loosens. TMR-TNT utilizes the idea of pushing the two ends of the rope towards the
knot, shortened tissue, to loosen it.
The baby doll with the strategically placed electrical tape was left for the mother in the
event she was unable to remember patient positioning and also to help teach the patient’s two
17
other caregivers, father and grandmother, how to do the technique as well. The mother was then
given the opportunity to complete the TMR-TNT technique with her son at the end of the first
treatment session so the student physical therapist could observe. The mother sat on the couch
and held the patient in her arms, like the student physical therapist did on the floor, and
completed the technique. The mother was instructed how to complete the technique just as the
student physical therapist initially did. She was also educated that when she felt him relax to
assist him to his new available body motion range. The mother competed the next sustained hold
for 5 minutes and demonstrated competency of executing the treatment.
The mother was instructed to do TMR-TNT sustained holds every day and as often as
possible. She was given a blank monthly calendar to document the number of minutes completed
each day and the total number of minutes completed for the week are reported in Table 4. The
patient was to be re-screened every visit, pre- and post- treatment, with reported documentation
during weeks 1, 4, and 7 during the patient’s home visits (Table 3). After the re-screen the
student physical therapist could determine if changes or progression to the initial TMR-TNT
technique needed to be made and if there was any progress of myofascial restrictions by
assessment of body motions. The mother was provided with the student physical therapist’s
contact information so if she had any questions, she was able to contact her. The mother was also
left with the baby doll in the event that she needed a visual reminder for positioning or to teach
the patient’s two other caregivers.
During week 4, home visit 3, the student physical therapist decided to progress treatment
by incorporating a trunk flexion component to the patient’s static TMR-TNT hold. This
progression was added because the patient exhibited little to no trunk extension as noted by
skilled observation in prone positioning. The goal with adding this additional position of trunk
18
flexion was to further increase the patient’s position of comfort and release myofascial
restrictions limiting trunk extension. While sitting on the couch the student physical therapist
held the patient in her arms and on her lap. The student physical therapist placed one hand under
the patient’s occiput and the other on his sacrum to induce trunk flexion. The patient was then
moved into left SB-BU and followed by left UT, positioning in three planes of motion (Figure 8).
The patient was held in this static position for 13 minutes by the student physical therapist and as
done during initial treatment session, as the patient further relaxed, he was moved into his new
available body position range. The mother again demonstrated competency of the additional
motion during the static hold technique by properly completing the hold for 5 minutes. The
mother was instructed to progress to only performing the 3-motion hold for the remainder of the
treatment.
During TMR-TNT holds, it was observed that the patient was comfortable and tolerating
treatment. There were no signs of agitation or painful stretching, further confirming the rationale
for treatment positioning.
Other interventions were completed during TMR-TNT intervention period. During home
visit 3 and 4, bilateral pectoralis traction was performed by the student physical therapist while
the patient was seated on her lap. This was added to the patient’s home exercise program as the
patient’s mother enjoyed this stretch for her child. Another manual technique was incorporated
during home visit 4 and 5. The student physical therapist used counter pressure applied with one
hand on patient’s chest and other on his lower thoracic, upper lumbar spine region to create trunk
extension. During home visit 4, the student physical therapist also brought some equipment for
the family based off mother report of what she wanted for her child. The equipment included a 6-
in wedge for inclined prone positioning during tummy time and a supported seating system
19
(Squiggles Early Activity System, Leckey Inc, Lisburn, United Kingdom). Proper developmental
positioning can aid in gross motor development. The Early Activity System was implemented by
the student physical therapist to help with pelvis positioning during sitting. The sitting support
with positioning strap allowed the patient to be positioned in proper supported sitting. One
medium roll was folded in half and placed between the patient’s lower extremities to prevent
pelvis from sliding out of position into posterior pelvic tilt position.
Outcomes
From skilled observations and photo documentation, the patient had significant
improvements in supine resting posture. During week 1, the patient displayed high flexed tone in
bilateral upper extremities, increased left lateral trunk flexion, and greater flexor tone in his right
lower extremity compared to the left. By week 7, the patient showed significant improvements in
upper extremity high flexed tone as documented by his resting arm position (Figure 1). His upper
extremities were symmetrical and down at his sides with elbow extension, however, shoulder
internal rotation was still observed bilaterally. The patient’s trunk appeared symmetrical in
midline and the right lower extremity also presented with decreased flexor tone, compared to
week 1, resulting in symmetrical positioning of bilateral lower extremities. Overall, the patient
presented with a more relaxed symmetrical posture while in a supine position.
The TMR-TNT treatment was implemented multiple times per week predominately by
the patient’s caregivers: mother, father, and grandmother. The student physical therapist also
completed TMR-TNT holds bi-weekly during home visits, with the exception of week 2 due to
patient cancellation. Adherence of TMR-TNT treatment was based off collection of blank
calendars to track treatment hold minutes as provided by the student physical therapist and parent
report from mother as she was the only caregiver who attended physical therapy home visits. The
20
results from the TMR-TNT screening assessment and myofascial restriction grading scale
showed minimal, but increased movement, in all four body motions screened. The biggest
improvements in body motions from week 1 to week 7 were seen in the patient’s right UT with a
change of 90% to 70% and left AR with a change of 60% to 40%. All other body motions had a
change of 10% at some point between week 1 and week 7 with the exception of left SB-BU with
no change of 90% (Table 3).
Another positive finding was the increase in symmetry between bilateral body motions,
by week 7 all motions were symmetrical with the exception of LR which still displayed more
restriction with right LR. Due to the limited research on the TMR-TNT screening assessment,
there is no minimal detectable change established. Improvements were documented in all four
body motions, as noted by the decrease in percent scores, with the expectation of one body
motion where no change was seen.
During initial PDMS-2 testing the patient’s adjusted age was 11 months and at final
testing he was 13 months. The results from the PDMS-2 showed that the patient had an increased
score in both stationary and locomotion subtests. The increase was by 1 point for stationary and
2 points for locomotion, while the reflex subtest resulted in no change. The total gross motor
composite score at week 1 was 15 and by week 7 it was 18 (Table 1). Due to lack of clinician
judgment and small sample population of children with CP tested using the PDMS-2, data for
determining minimally clinically important change was insufficient.31 Although the changes in
raw scores were small, positive improvements in gross motor function were seen.
The 1-point improvement in the stationary subset was seen in aligning head while child
was gently bounced up and down three times by examiner at shoulder height. Prior, the patient
was unable to hold his head in midline for one bounce, resulting in a score of 1 point. During
21
final PDMS-2 examination the patient was able to hold head in midline for more than 2-3
bounces, receiving a max score of two. The 2-point improvement seen in the locomotion subset
was a big accomplishment for the patient. During initial examination, the patient was unable to
move either upper extremities to a toy presented in midline. During final examination the patient
was able to bring both hands together at midline and grasp his toy within 5 seconds. The student
physical therapist also noted that when reassessing the PDMS-2, the patient exhibited emerging
gross motor skills. The significance of this is even though the patient did not receive a score for
the item, improvements were observed from initial examination.
Discussion
Cerebral Palsy is the most common physical disability in children with impairments that
directly impact the child’s mobility.1,2 Children diagnosed with CP live a more sedentary
lifestyle compared to typically developing children due the direct impairments associated with
damage to the developing brain.1,2 With limited activity, adhesions in myofascial tissue can
cause muscles to contract and shorten leading to myofascial restrictions.7
The purpose of this case report was to describe the effects of TMR-TNT as a treatment
method for myofascial restrictions to restore ROM, progress motor development, and achieve a
symmetrical supine resting posture in a child with CP. The myofascial restriction grading scale,
PDMS-2, and photographs were used to document patient changes during the TMR-TNT
intervention period.
The TMR-TNT intervention targeted the patient’s myofascial restrictions that were
identified by the student physical therapist using the TMR-TNT screening assessment and
interpreted through the myofascial restriction grading scale. The TMR-TNT prolonged static
holds were implemented by the student physical therapist and patient’s caregivers to decrease
22
myofascial restrictions with the goal of restoring ROM, increasing gross motor function, and
achieving a symmetrical supine resting posture.
The patient’s final PDMS-2 raw scores increased in both stationary and locomotion
subtests. The patient had an increase of total gross motor composites scores of 15 at week 1 to 18
by week 7. Although the changes in raw scores were small, positive improvements in gross
motor function were documented. The student physical therapist also noted, when reassessing the
PDMS-2, the patient exhibited emerging gross motor skills, meaning they did not receive a score
for the item, but improvements were observed from initial examination.
There is no documented research on the use of TMR-TNT as a treatment method for the
pediatric patient population. However, there is documented research on TMR, which uses the
same strain counterstain method as TMR-TNT.19 However, TMR is predominately used with
typically developing adults because the treatment is executed independently by the patient with
active motion.19
In a randomized controlled trial, the effect of TMR on Functional Movement Screen
(FMS) composite scores were assessed. The FMS is used to assess stability, mobility, and quality
of movements as well as identify asymmetries.34 Although the FMS typically assesses more
complex movements in adults compared to the PDMS-2 in a child with CP, there are similarities.
Both the FMS and PDMS-2 are geared towards specific patient population to assess full body
movement quality and patterns. 34 The participants in this study were healthy with a mean age of
25.7 years, compared to the child in this case report whose adjusted age was 11 months at initial
visit and has a diagnosis of CP along with many other medical involvements. The research
showed that the FMS scores of the TMR group significantly improved (P  .001) compared to
23
the control group after a 20-minute TMR treatment period.34 These results indicate a single
treatment session of TMR can produced immediate improvements in FMS scores.34
The total change in gross motor composite scores on the PDMS-2 for the patient in this
case report was only 3 points and occurred over a time span of 7 weeks. The TMR-TNT results
exhibited in this case report were not immediate like the results exhibited in the single 20-minute
TMR treatment group from the randomized controlled trial above. The gross motor outcomes on
the PDMS-2 for the patient in this case report were not statistically significant, but positive
improvements were observed in gross motor function and overall movement quality. In the
randomized controlled trial above, there was a statistically significant improvement in FMS
scores in the TMR group compared to the control group. Even though the PDMS-2 results of this
case report were not statistically significant, like they were in the randomized controlled trial
above, during the TMR-TNT and TMR intervention period patients improved in full body
movement.
During the initial visit, the patient demonstrated central hypotonia with increased tone in
his upper extremities and mild hypertonia in lower extremities. His supine resting posture was
asymmetrical and functional movements appeared to be limited. A through search on the use of
TMR-TNT or related manual therapy techniques to improve postural asymmetry yielded no
documented research. However, the patient in this case report demonstrated significant
improvements in supine resting posture as noted by photo documentation. By week 7 the
patient’s supine resting posture appeared symmetrical with upper extremities resting in a more
neutral position at his sides.
The outcomes of this case report provided the evidence that TMR-TNT may help assist in
achieving a more neutral and symmetrical supine resting posture as well as aid in the progression
24
of gross motor development. Despite some of the positive outcomes in this case report, this
report is not without limitations. The mother reported that she forgot to fill out the calendar,
tracking minutes of TMR-TNT completed each day, during the first week of treatment as well as
not being thorough during 2 additional weeks. Since TMR-TNT treatment time is tracked via
parent documentation, inaccuracies may be present. The patient is also a child who is still
developing, therefore increased score on PDMS-2 may be due to continuous development and
the 2-month age difference between baseline and final testing.
Further research with a greater number of pediatric patients with CP is needed to determine
the treatment effects of static TMR-TNT holds. It is important to determine if the treatment will
create positive results over a larger population. The TMR-TNT screening assessment and
myofascial restriction grading scale is also highly subjective as it is based on the examiner’s
palpation and interpretation of myofascial restrictions. Further researcher needs to be done in
order to determine validity and reliability of this measurement tool. Range of motion
measurements should be added to this TMR-TNT assessment to make it more objective and
increase validity.
Given the limited risks of this novel intervention, clinicians can utilize the outcomes in
this case report when considering treatment options to target myofascial restrictions limiting
ROM in a child with CP. However, this case report is based on a single patient outcome, without
a control, and should not be generalized to the public or those diagnosed with CP.
25
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29
Table 1.
Peabody Developmental Motor Scale – Second Edition (folio)27 (PDMS-2) Scores27 (folio)
Gross motor subtest Raw Score Percentage Score Raw Score Percentage Score
(max subtest raw week 1 week 1 week 7 week 7
score)
Reflexes 2 12.5% 2 12.5%
(16)
Stationary 11 18.3% 12 20.0%
(60)
Locomotion 2 1.1% 4 2.2%
(178)
Total Gross Motor 15 10.6% 18 11.6%
Composite
30
Table 2.
Hammersmith Infant Neurological Exam28,29,30 (HINE) Scores and Description
Domain Patient’s Score/ Description

Max Score
Cranial 12/15 The patient lost points for poor suck and swallow. As
Nerve well as slightly atypical smile and reaction to stimuli
Function by closing eyes and grimacing.
Posture 5/18 Overall low scores reflect low tone centrally at rest in
sitting as noted by forward flexed posture of truck and
unsustained head control. The patient also exhibited
marked internal rotation of arms and external rotation
of legs at rest in sitting.
Movements 1/6 Minimal voluntary movement in supine. The
movements that were observed appeared jerky.
Tone 16/24 Passive range resulted in resistance to full
pronation/supination, about 90 degrees achieved for
popliteal angle, and elbow not crossing midline for
scarf sign. When held in ventral suspension little to no
trunk/neck extension while upper and lower extremities
remained in slight flexion.
Reflexes 3/15 No protective arm reactions, arms remain in fully
and flexed position. Vertical suspension the patient
Reactions displayed poor kicking that was delayed. Lateral tilting
right slight lift of legs left. Lateral tilting left absent
reaction. Forward parachute reflex absent. Deep tendon
reflexes (biceps, knee, ankle) absent.
Global 37/78 Global score of <40 in association with sever CP and
Score motor impairments with inability to sit independently
at 2 years of age.29
31
Table 3.
Total Motion Release Tots and Teens10 (TMR-TNT) Screening Assessmenta and Myofascial
Restriction Grading Scaleb
Week Body Patient Position Left (Color, %) Right (Color, %)

Motion
1 UT Sitting Red, 80 Red, 90
4 UT Sitting Red, 80 Red, 80*
7 UT Sitting Red, 70* Red, 70*
1 SB-BU Sitting Red, 90 Red, 100
4 SB-BU Sitting Red, 90 Red, 90*
7 SB-BU Sitting Red, 90 Red, 90
1 AR Supine Yellow, 60 Yellow, 50
4 AR Supine Yellow, 50* Yellow, 50
7 AR Supine Yellow, 40* Yellow, 40*
1 LR Supine Red, 80 Red, 90
4 LR Supine Red, 80 Red, 90
7 LR Supine Red, 70* Red, 80*
*= decrease in body motion restriction from previous grading week
a UT = upper twist assessing trunk rotation, SB-BU = side-bending bottom up assessing lateral
trunk flexion by moving patient’s pelvis, AR = arm raise assessing shoulder flexion, LR = leg
raise assessing hip flexion
b Red = high body motion restriction 70-100%, Yellow = medium body motion restriction 40-
60%, Green = low body motion restriction 0-30%
32
Table 4.
Total Motion Release Tots and Teens10 (TMR-TNT) Static Hold Total Minutes Per Week.
Week Total Minutes of

static hold
1 10
2 30
3 195
4 90
5 180
6 100
7 80
33
Week 1 Week 4 Week 7

Figure 1.
Progression of supine resting posture as documented through photographs taken at weeks 1, 4,
and 7. Visual documentation of advancement to a more symmetrical, neutral resting posture from
week 1 to 7.
34
Figure 2.
Upper trunk rotation bod motion assessment in sitting. Hands placed under the axilla to assess
rotation restrictions bilaterally. This body motion assessment is referred to as upper twist (UT).
35
Figure 3.
Lateral trunk flexion body motion assessment with patient upright and pelvis moved to assess
lateral trunk flexion restrictions. The motion assessment is referred to as side-bending bottom up
(SB-BU).
36
Figure 4.
Shoulder flexion body motion assessment in supine. This motion assessment is referred to as arm
raise (AR).
37
Figure 5.
Hip flexion body motion assessment in supine. This motion assessment is referred to as leg raise
(LR).
38
Figure 6.
Myofascial restriction grading scale used to interpret body motion restrictions felt by examiner.
Three color system grading body motion restriction interpreted by examiner as either red,
yellow, or green. Percent score assigned by examiner to further distinguish difference in
restriction between bilateral body motions assessed. Percent scores range from 0% to 100%.
39
Figure 7.
Passive, static treatment hold with the patient first side-bent bottom up (SB-BU) into left lateral
trunk flexion, followed by left upper twist (UT) into trunk rotation. Treatment hold provider
places left hand under patient’s left upper leg to assist left SB-BU. Treatment hold provider
places right hand on patient’s right upper extremity to assist left UT. The treatment hold provider
moves patient into end of available body motion range.
40
Figure 8.
Passive, static treatment hold with the patient first moved into trunk flexion, followed by side-
bent bottom up (SB-BU) into left lateral trunk flexion, and finally by left upper twist (UT) into
trunk rotation. Treatment hold provider placed left hand under patient’s occiput and right hand
on his sacrum to induce trunk flexion. The treatment hold provider’s right hand on the sacrum
also assisted the patient into left SB-BU. The treatment hold provider’s left hand on the occiput
and left forearm assisted with left UT. The treatment hold provider moves patient into the end of
available body motion range.
41

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Author: Allison R. Wierda

Doctoral Program in Physical Therapy

Date (Month, Day, Year)

Submitted to the Faculty of the

Doctoral Program in Physical Therapy at

Central Michigan University

In partial fulfillment of the requirements of the

Doctorate of Physical Therapy

Accepted by the Faculty Research Advisor

(Electronic or Written Signature here)

Karen E. H. Grossnickle, PT, DHSc

Background and Purpose

Peabody Developmental Motor Scales-Second Edition (PDMS-2), TMR-TNT screening

posture were used to track patient progress.

presentation may consider TMR-TNT as a possible treatment option.

Background and Purpose

Cerebral palsy (CP) is a non-progressive neurological condition which is caused by injury

In pre-term babies, between 22 to 27 weeks of gestation, the prevalence of CP significantly

communication, sensation, perception, and behavior. 4

Since CP impairs the neuromuscular and musculoskeletal systems, it often leads to

leading to myofascial restrictions.7 These myofascial restrictions can potentially restrict an

individual’s range of motion (ROM).7

exhibited in gross motor, fine motor, and participation outcomes.5

gross-motor development occurring between 1.5 to 5 years of age.4,5 In a longitudinal study of

period for gross-motor development.4

neurodevelopmental therapy, orthotics (splints), and passive stretching.8,9 Documented research

continues to remain unclear.

movement.10,11,12 The TMR-TNT technique is based off the strain-counterstain method.11,12

Strain-counterstain is a manual therapy technique that was developed in 1955 by

muscle by automatically increasing contractility, as long as the stretch is within physiological

as increase muscle tone via the stretch reflex. 16

position avoids muscle spasm.18

TMR-TNT is a favorable treatment as it offers unique features that lead to parent

comfort eliminating the possibility of a painful stretch.12

Documented research on TMR-TNT as a treatment intervention to resolve myofascial

executed independently by the patient with active motion.19

with moderate to severe CP.21

Further research is needed to explore the use of TMR-TNT as an intervention for

patient changes during the TMR-TNT intervention period.

Graduate Studies of Central Michigan University.

Patient History and Systems Review

He was diagnosed with CP by a neurodevelopmental pediatrician and has multiple medical

present in his upper extremities compared to his lower extremities.

removal of supplemental oxygen.

weekly for 60 minutes.

movement and independence.

with limited mechanoreceptor activation, leading to skeletal deformation, adaptive muscle

explore their environment.12,25

According to research, children diagnosed with CP live a significantly more sedentary

avoiding those movements that are more challenging.12

appropriate to help identify the patient’s neurological function.28,29,30

The TMR-TNT screening assessment would be used to identify myofascial restrictions in

motor development. A thorough examination of gross motor development, utilizing PDMS-2,

visually track increased symmetry of supine resting posture.

pull to sit, as noted by his facial expression.

and qualitative rating criteria.31

involvements, reflexes were deemed appropriate to assess. A student physical therapist

PDMS-2 related to children with CP.

PDMS-2 at initial examination are shown in Table 1.

Hammersmith Infant Neurological Examination. The HINE was developed to assess

that is scored is the neurological examination.28

accuracy but does not typically result in an overdiagnosis.30