TMR TOTS
Parent Handouts
Copyright (c) 2011 Susan M Blum
(May be reproduced only for patient use)
PARENT'HANDOUTS'
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Copyright'©'2012'Tom'Dalonzo'Baker'&'Susan'M.'Blum''
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(Handouts'may'be'reproduced'for'patient'use'only)''
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A. TMR'Tots'Motions''
Upper'Twist'
Side'Bends''
Arm'Raise''
Leg'Lift''
Lower'Twist''
Leg'Dangle''
Stand'to'Sit''
Arm'Press''
Flexion'Extension''
Lateral'Hip'Shift''
Bent'Knee'Toe'
Therapeutic'Play''
''''''''''Crunches''''
Side'Bend'
''''''''''''Rolling''
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B. Tortisoma'Screening''
''''''''''''Multi'move''
Onesie'Test''
Pendulum'Test''
Knee'to'Elbow''
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'''''C.''4'Motions'per'sheet''
TOTAL MOTION RELEASE – Instructions for Testing
Diagrams, TMR Tots Test Positions and Instructions developed and Copyright © 2012 Susan M. Blum PT
ASSESSMENT OF FLEXIBILITY – Look for limits in flexibility and changes in muscle tension.
These restrictions need interventions because they prevent learning to move properly.
----- Until there are no restrictions, we only work on strengthening the easy side muscles – not the hard side.
------After both sides are the same, we can strengthen both sides.
TEST POSITION
Take your time with test positions to get the most accurate response. Slow movement is less likely to cause
muscles to resist the movement.
Easy/Hard
A. Upper Trunk Twist (See diagram A) – The child sits with hips supported so they do not move. Use a
preferred item to encourage the child to turn and look towards the right, then the left. Rotation is measured
by looking at the breastbone, not the face. If the child does not have good sitting balance to rotate, use
very gentle physical guidance in addition to something to look at.
The easy side has the most upper trunk rotation.
B. Side bend of the trunk – (see diagram B)
Easy Side –
--- B1. Shoulder Down Strategy - also known as top down strategy (See diagram B1) – The child can lie
down or sit up. Slowly and gently guide one shoulder down while the child pays attention to something else.
Then do the same with the other shoulder.
The shoulder that gets closest to the bottom of the ribs is the easy side
.
--- B2. Hip Up Strategy – also known as bottom up strategy (See diagram B2) – The child can lie down, or
sit on one hip on an adult leg. When lying down, raise one hip close to the ribs on the same side. Then do
the same with the other hip. When sitting, the hip the child sits on is automatically raised.
The hip and lower ribs get closest together on the easy side. In sitting, balance control may be best on
the easy side.
C. Leg Raise (See diagram C) – In sitting, he child leans back, gently resting on something or someone.
Guidance may be needed to keep knees straight. First one leg is lifted. Then the other leg.
The leg that goes highest (with knee straight) is the easy side.
D. Arm Raise (See diagram D) – The child lies down or sits. The elbow is straight and the palm faces the
side of the head. Help can be given to keep the palm facing the side of the head. One arm is lifted first.
Then do the other arm. Look at how high the straight arm goes up - to shoulder, chin, cheek, ear, behind ear
and how far behind ear. Older children can independently reach up to get toys.
The arm that goes up farthest is the easy side.
E. Lower Trunk Twist (See diagram E) -- The child lies down. Rotate pelvis bone to one side first, then the
other side (i.e. during diapering). Do not hold leg bones. The shoulders need to stay flat on the surface, and
may need support. The child can be held against your chest, supporting the lower ribs and rotating the pelvis
bone (see addendum page for further instructions).
The easy side has the most lower trunk rotation.
Shoulder Down Easy Side –
F. Sit to stand lying down (See diagram F) -- Lift both knees to the chest, then lower one leg so it
straightens as much as it can. Do not force or push. Again lift both knees to the chest and lower the other
leg.
1
Hard Side –
Shoulder Down Hard Side Hip Up Easy Side Hip Up Hard Side Easy Side Hard Side Easy Side –
Hard Side Easy Side –
Hard Side NOTE: Must be opposite A.
otherwise it is not correct.
Straight Leg Easy Side –
Straight Leg Hard Side -
Scoring TMR
#
** See
instructions
TOTAL MOTION RELEASE – Instructions for Testing
The easy side is the leg that gets the straightest.
H. Arm Press (See diagram H) – The child lies on his/her stomach and uses arms/elbows to push up or for
crawling. Look for the arm/hand that reaches forward and/or up to get what is wanted.
The arm that supports the child while the other reaches or grasps, is the easy side.
G. Sit to stand standing up (See diagram G) -- The child stands, with help if needed (from furniture or from
a person). Support one leg so the child is standing on one leg. Assist the child to lower towards sitting
while standing on 1 leg. Look at the supporting leg as it bends to lower the child.
The leg that supports the child longest as the child lowers is the easy side.
Support Arm Easy Side –
Support Arm Hard Side Supporting Leg Easy SideSupporting Leg Hard Side-
Karen A. Aukland PT, PCS contributed to the development of family friendly language
** Instructions for Scoring Differences
1.
2.
3.
How do we define the difference? What are we really comparing? The number given is based on any one or combination of these factors.
a.
How far can the child move (range)
b.
How hard is it for the child to move (avoidance, speed, effort, control, use or function)
If there is no difference between the 2 sides – it gets no score
If there is a difference – it gets a score. The score is based on comparing the Hard side to the Easy side.
i. Look at the easy side first – think about it as the best – no problem
ii. Then look at the hard side – give it a label based on how big the difference is
1. The easy side is best and the hard side goes up only a little bit – put down “Big” (for Big Difference between easy and
hard side).
2. The easy side is best and the hard side goes up somewhere in the middle - put down “Medium” (for Medium Difference).
3. The easy side is best and the hard side goes up most of the way – put down “Small” (for Small Difference).
Look at the scores. Choose 2 positions for interventions
Scores in “Big” get worked on first.
Scores in “Medium” get worked on later when there are no “Bigs” to work on.
Scores of “Small” may or may not need to be worked on but would be last.
Causes of asymmetric restrictions in range
1.
Structural (bone alignment, ligamentous tightness, fascial restrictions)
2.
Pain
3.
Strength
4.
Muscle tension
5.
Motor control
.
Therapist: ________________________________
2
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Multi Move – Test and Treatment
Right Elbow to Left Knee
(= Easy Side)
Left Elbow to Right Knee
(= Hard Side)
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Flexion / Extension
(opt.) Flexion + Left
Upper Twist
Combo
Extension
Hard
Side
Flexion Easy Side
Hold
Flexed to
Release
Bring right shoulder
toward Left Hip
EG: G-Tube
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Upper Twist
Or
Face Forward:
Face Caregiver:
Legs over right
Legs over left
side of lap
side of lap
Left Upper Twist
Sit with left side
of chair by table
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Arm Raise
Reach Up & Back
Raise arm alongside ear
with thumb back.
Note where stops.
(eyebrow, front or back of ear)
Copyright © 20 Thomas Dalonzo-BakerBOE4VTBO.#MVN
Leg Raise
Sit behind child to support.
Hold leg below knee and slowly, gently
raise up until you feel first resistance
(no stretching!)
L
The leg that goes higher is the Easy side.
Gently hold at limit (2 minutes).
Bring foot higher as tissues lengthen.
R
Copyright © 20Thomas Dalonzo-BakerBOE4VTBO.#MVN
Lower Twist – Right
STEP 1
STEP 2
STEP 3
Left Hand Holds
Child Back
Against Chest
Right hand
Threads between
Legs and
Scoops buttocks
Right hand
Pulls Pelvis ( Not Legs)
Rotating to Right
(Left hand holds upper
body in place)
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Combo
Left Upper Twist/ Right Lower Twist
Child on right side
Left Palm cups buttocks
and Pushes Forward
Right Palm on ribs,
Fingers pointed to
belly button and
Pulls Back
Gently pick up the slack and hold, waiting for release
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COMBO Upper Twist (left)/Lower Twist (right)
STEP 1
STEP 2
STEP 3
STEP 4
Left Hand Holds
Child Back
Against Chest
Right hand
Threads between
Legs and
Scoops buttocks
Right hand
Pulls Pelvis ( Not Legs)
Rotating to Right
(Left hand holds upper
body in place)
Left hand Pulls Back
Follow the child into motion
Pull evenly as he releases
both ways while your right
elbow pulls to right, left
elbow pulls to left
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Arm Press
Kneeling child,
support under
chest & lower to
floor so that he
pushes self up
with elbow almost
straight.
(Option)
The child may do the
Arm Press with weight
on the elbow.
Reach for toy with one hand.
The preferred arm for support is
the Easy Side
NOTE: the Body Weight is on the Hand or the Elbow
Copyright © 20 Thomas Dalonzo-BakerBOE4VTBO.#MVN
Bent Knee Toe - Sitting
Child sits on floor and bends knee and ankle.
B
A. Slide heal to buttock.
B. Flex toes to nose.
A
Easy Side flexes “backward” move.
B
A. Note distance between heal and buttock
B. Note sock wrinkles.
A
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Bent Knee Toe Reach
Child Holds Table or Your Hand.
Stands on One Foot
Keep Other Foot Slightly Off Floor.
Easy Side is One That
Lowers (flexes) More.
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Side Shift
Treat
Test
Hold
Push
Hard
Side
Easy
Side
Shoulders Level – Shift to Side
The Side Which Goes Further = EASY SIDE
Easy
Side
Push Deeper Into EASY SIDE
(Hold Ribs Still on Opposite Side)
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Right Elbow to Left Knee
Position
Crunch
Whole Motion
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Therapeutic Play – Rolling
Left Upper Twist
Right Lower Twist
Arms to Left
Pelvis to Right
Toy Slightly Out of Reach
with Right Hand
1
Touch Paper With
Left Foot
2
3
Reach With Foot
in a Long Arc
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Upper Twist
Or
Face Forward:
Face Caregiver:
Legs over right
Legs over left
side of lap
side of lap
Left Upper Twist
Sit with left side
of chair by table
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Leg Raise
Sit behind child to support.
Hold leg below knee and slowly, gently
raise up until you feel first resistance
(no stretching!)
L
The leg that goes higher is the Easy side.
Gently hold at limit (2 minutes).
Bring foot higher as tissues lengthen.
R
Copyright © 20Thomas Dalonzo-BakerBOE4VTBO.#MVN
Therapeutic Play – Rolling
Left Upper Twist
Right Lower Twist
Arms to Left
COMBO Upper Twist (left)/Lower Twist (right)
Pelvis to Right
Toy Slightly Out of Reach
with Right Hand
1
Touch Paper With
Left Foot
2
3
Reach With Foot
in a Long Arc
STEP 1
STEP 2
STEP 3
STEP 4
Left Hand Holds
Child Back
Against Chest
Right hand
Threads between
Legs and
Scoops buttocks
Right hand
Pulls Pelvis ( Not Legs)
Rotating to Right
(Left hand holds upper
body in place)
Left hand Pulls Back
Follow the child into motion
Pull evenly as he releases
both ways while your right
elbow pulls to right, left
elbow pulls to left
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Copyright © 204VTBO.#MVN
Combo
Lower Twist – Right
Left Upper Twist/ Right Lower Twist
Child on right side
STEP 1
STEP 2
STEP 3
Left Hand Holds
Child Back
Against Chest
Right hand
Threads between
Legs and
Scoops buttocks
Right hand
Pulls Pelvis ( Not Legs)
Rotating to Right
(Left hand holds upper
body in place)
Copyright © 204VTBN.#MVN
Left Palm cups buttocks
and Pushes Forward
Right Palm on ribs,
Fingers pointed to
belly button and
Pulls Back
Gently pick up the slack and hold, waiting for release
Copyright © 204VTBO.#MVN
Bent Knee Toe - Sitting
Arm Press
Child sits on floor and bends knee and ankle.
B
A. Slide heal to buttock.
B. Flex toes to nose.
A
Kneeling child,
support under
chest & lower to
floor so that he
pushes self up
with elbow almost
straight.
(Option)
The child may do the
Arm Press with weight
on the elbow.
Reach for toy with one hand.
The preferred arm for support is
the Easy Side
Easy Side flexes “backward” move.
NOTE: the Body Weight is on the Hand or the Elbow
Copyright © 20 Thomas Dalonzo-BakerBOE4VTBO.#MVN
B
A. Note distance between heal and buttock
B. Note sock wrinkles.
A
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Arm Press
Kneeling child,
support under
chest & lower to
floor so that he
pushes self up
with elbow almost
straight.
(Option)
The child may do the
Arm Press with weight
on the elbow.
Reach for toy with one hand.
The preferred arm for support is
the Easy Side
NOTE: the Body Weight is on the Hand or the Elbow
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Copyright © 20 Thomas Dalonzo-BakerBOE4VTBO.#MVN
Side Shift
Treat
Test
Hold
Push
Hard
Side
Easy
Side
Shoulders Level – Shift to Side
The Side Which Goes Further = EASY SIDE
Easy
Side
Push Deeper Into EASY SIDE
(Hold Ribs Still on Opposite Side)
Copyright © 204VTBO.#MVN
Therapeutic Play – Rolling
Left Upper Twist
Right Lower Twist
Arms to Left
Pelvis to Right
Toy Slightly Out of Reach
with Right Hand
1
Touch Paper With
Left Foot
2
3
Reach With Foot
in a Long Arc
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Copyright © 204VTBO.#MVN
Flexion / Extension
Right Elbow to Left Knee
(opt.) Flexion + Left
Upper Twist
Combo
Extension
Hard
Side
Flexion Easy Side
Hold
Flexed to
Release
Bring right shoulder
toward Left Hip
EG: G-Tube
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Position
Crunch
Whole Motion
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Lower Twist – Right
STEP 1
STEP 2
STEP 3
Left Hand Holds
Child Back
Against Chest
Right hand
Threads between
Legs and
Scoops buttocks
Right hand
Pulls Pelvis ( Not Legs)
Rotating to Right
(Left hand holds upper
body in place)
Copyright © 204VTBN.#MVN
Upper Twist
Or
Face Forward:
Face Caregiver:
Legs over right
Legs over left
side of lap
side of lap
Left Upper Twist
Sit with left side
of chair by table
Copyright © 2014VTBO.#MVN