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Pediatric Seminars
Click the link - TMR 1 Pediatric Seminars below for Dates, Locations & Course Description
This course will teach the Pediatric Therapist the skills of Total Motion Release on children. It will be taught both by Susan Blum, PT. You will receive 30 credit hours for this course. (The amount of hours approved per state varies. Click Here to see state approvals - this is considered TMR level 1). The seminar meets Sat 8am - 6 pm, and Sunday 8am - 2pm. There is Pre & Post Seminar work that will be sent to you via a DVD. It is recommended you do the Pre-Seminar Work on yourself prior to the seminar, so that you know the basics of TMR.
Click Here for the Monthly Pediatric Blog by Susan Blum, Pediatric PT.
Click Here to See Videos of TMR being done on Pediatric Patients
What is pediatric TMR?
How is pediatric TMR the same/ different? The pediatric approach was developed as a modification of TMR as developed by Tom Dalonzo Baker. Using the information Tom taught in TMR 1, I was able to use 25 years in pediatrics preceded by experience in home health and adult orthopedics to adapt the approach to meet the needs of children.
Changes included: to teach the parent (rather than the patient), to change the issue to achievement of a functional outcome (rather than elimination of pain/ immobility), to modify FAB5 positions to meet the developmental level of the child assisting them to move in direction (rather than exclusively active), to add therapeutic positioning (melting, relaxation) using the FAB 5 motions, and to use the achievement of symmetrical mobility as a foundation for the application of other pediatric techniques and skill development.
What type of patient can this help?
Some of the most dramatic successes have been with patients who I was treating pre-TMR as well as those who were discharged from other therapists after hitting plateaus. Included in this group and ( key release/s for this child) include:
- The boy with torticollis and hypotonia featured in the webinar. (upper twist and leg lift);
- A girl w/ spastic diplegia tried to pull to stand with great difficulty at 25 months, able to take independent steps at 31 months and after 35 more months walks all around the house. . (upper trunk twist/ arm raise combination);
- A girl w/ Spina Bifida with Chiari malformation post surgery scar with zero cervical rotation to the left and could only roll to one side now all ranges and mobility within functional limits (leg lift and lower trunk twist);
- A boy with multiple handicaps and PVL that developed Legg Perthes who after doing TMR on the left LE while NWB for 4 months NWB on the right kept strength and increased range in his right LE. On the first day he was allowed WB he had better gait than pre Legg Perthes. (modified assisted sit to stand);
- A girl with sensory processing/proprioceptive issues, toe walking with wide base and trying to weight bear on the dorsum of her feet. With TMR able to determine which leg better and used that to enhance her awareness of body position in space to get heels down and narrow base of support. (trunk twist and modified bent knee toe reach);
- A girl with severe toe-in gait using TMRable to treat medial hamstring shortening to bring feet more neutral and stop falling. (modified leg lift and upper trunk twist);
- A boy with infantile spasms, extreme tonal issues and sacral sitting, who with TMR therapeutic positioning able to relax and rotate trunk with ease. This decreased thrusting into extension in LEs and child now able to move legs reciprocally and sit up in high chair. (trunk twist/ side bend combo);
- A boy who was a shaken baby improved posture (using twists and side bends that simulate his wind swept posture.)
- A boy who was labeled developmental delay – clumsiness and with uneven weight on his heels and more weight on one forefoot was able to balance equally and learn to a kick ball (trunk twist)
How does TMR approach complement NDT?
TMR and NDT both address alignment, elongation and activation. When a child is evaluated using the FAB5, we look at lack of elongation or limits in range that compromise the child’s alignment. Better symmetry in alignment is achieved as range improves using elongation on one side and shortening on the other. With improved alignment we can progress toward further elongation. As elongation increases many children are able to discover how to move in ranges that were previously inaccessible to them due to soft tissue restrictions. Ultimately as he progresses with the resistance of gravity and finally additional resistance the child develops control in these ranges. While treatment combining the 2 approaches may appear the same, my experience is that TMR has enhanced my NDT skills. The main differences are the ability to teach the parent and the amount of improvement in alignment which in turn increases the improvement in function. As with NDT, with each improvement the cycle repeats as there is an assessment of alignment, treatment with elongation repeatedly and activation of control leading to achievement of a functional outcome.
Is pediatric TMR active or passive? How can I use it with children that don’t have active control?
Motions are active assistive and active depending on the age and abilities of the child. When children are very young or have severe involvement there is still always a better side. This explained to the parent using the example that if they had to watch TV sitting side ways or relax curled up on their side in a bean bag chair there is one direction that would feel better to turn than the other. A child that has very limited movement (eg: severe tonal issues) also has a better side. It feels good / feels right when a child is guided into motion on the better side. Because it is comfortable the child is more likely to respond to facilitation to turn that way and the motion becomes more active. The parent or therapist can learn to feel the ease of motion as the body seems to MELT into that position.
Do all the children I see benefit from TMR? Is this all I do as treatment?
100% of the children that I treat receive a TMR evaluation as part of my complete evaluation of their gross motor levels. What I have found is that adding the TMR evaluation uncovered areas of asymmetry that may have otherwise been undetected and may have been delayed or prevented the child from fully achieving their potential. This is easy to illustrate in a child with torticollis when the objective is to have range within functional limits. Likewise in the child with an orthopedic diagnosis such as Legg Perthes where strength is assessed.
When we add TMR to our toolbox, seeing more dramatic improvement in these children is very exciting. When the child has more strength and range of motion we can use the many other tools that we have already been using such as NDT. I continue to use my balance boards step aerobic steps, bubbles and toys. The only difference is that my focus has changed a bit. TMR has given me a tool to look at the WHOLE child and to see and appreciate that subtle connections can have big impacts in allowing the child to discover how to move. In many cases such as in torticollis there have been drastic accelerations in progress. This is most evident when the focus is achievement of symmetrical movement in the pelvis. This in turn produces as stable base where the child is then able to right their head. Using an indirect approach such as this changes the neck posture without the need to touch the delicate neck musculature.
Other children have more subtle improvement. Small problems with balance or clumsiness have improved when even minimal differences in left/ right symmetry have been resolved with TMR. A child who has 65% of weight on one foot learns to balance to kick a ball better when he has more equalized base of support.
The successes for children with profound issues such as the child with spastic dipelgia have not been overnight, but have still been dramatic. Milestones have been achieved that far surpassed anything expected. The part of their therapy that was the same was months of work on balance, squats, ½ kneels, reaching for toys using facilitation and body awareness techniques etc. What was different was when we discovered that an upper trunk twist and arm raise released her tight hip flexors when I helped her stand she wasn’t in such a crouch gait! Was the reason she was stuck in a crouch the weakness of her hip extensors or the tightness of the flexors? This gave us both the opportunity to discover the possibility that we might get her hip extensors that were previously inaccessible to kick in. (This new range is what I call the discovery zone) Maybe the muscles would work or maybe not depending on the involvement of her CP, but now she had a CHANCE! TMR opened up a window of opportunity for the child. Over the months we repeated the cycle with each visit – recheck the FAB 5 – release the worst – work in the new ranges using the stronger side to gain strength– tweak the home program. 8 months of therapy later she can now walk independently up and down stairs and all around the house.
Teaching parents to treat their children
A unique component of TMR in the pediatric setting is the focus on teaching the parent. Need to achieve the functional outcome is the issue. Progress toward achievement is monitored as in traditional therapy. In the process of demonstrating the FAB5 to the parent, we help them learn by doing. As the parent holds their child and turns them from side to side, we assist them hand over hand to discover where there is drag or resistance to movement. They are reassured that we are only moving to the point of first resistance. Soon they develop improved sensitivity to their child’s abilities and needs and comment “now I see why she couldn’t turn to the side in the highchair!” As they learn to record the data on the pediatric TMR form they learn to determine if the exercise is working. The side with less range or strength is graded or given a report card as compared to the better -100% side. The cycle of treating, recording, analyzing is continued until the movement is symmetrical or the functional outcome is achieved. In the time between therapy visits the parents note the child improving eg: from 15% to 60% trunk twist and they are delighted to be able to note gains.
Parents are pleased with the ease of incorporating treatment into daily activities and play by therapeutic positioning and play activities.
Here’s an example: a child has uneven weight distribution on his ischial tuberosities and cannot balance and play with a toy on the right side.
We discover right twist is limited and do TMR toward the left. The parent uses the positioning to have the child turn to the left relaxing (melting) when sitting on their lap and reading a book. They spend three minutes at diapering time with hands on the child’s pelvis rotating to the good side. Later they sit and have a sibling play with a toy within the new range toward the right side. Between visits the parent notes the increasing range on the right and discovers which play activities the child enjoys to utilize the new range.
It has been so easy to teach TMR to the parents and a joy to see their satisfaction at being able to help their own child. Rather than dragging them from appointment to appointment and feeling helpless in between, they are empowered. Even a parent who was herself mentally retarded was able to help her son. We used a FAB5 form with pictures and she was able to note and check off his progress. She learned to feel which side he could turn and said, ” he can turn easier to the left – so we turn to the left” (He made outstanding progress and was soon able to be discharged!)
For children that have complex problems that may continue to have ongoing issues for years or a lifetime, parents develop the ability to be able to recheck their children to work on symmetry in the future or to determine when a PT visit is warranted. Examples would be a child with as CP that may change during growth spurts or issues like torticolls that may resurface at age 7 in the effort to stabilize while learning cursive writing.
What are parents saying?
(child with torticollis) “I’m so glad I can help my child so easily – I thought therapy would hurt!” “Who would want to stretch their child when you can hug her better?”
(after 5 visits at discharge) “We appreciate that you taught us how to work with our son and how to manage this problem now and in the future” “With us both working we didn’t know how we could fit all the therapy into the little time we have after daycare, but you showed us we could do it as we watch TV!” “We feel we can handle it well ourselves and have these forms to recheck him” “ You gave us the confidence to handle this issue on our own and know when to call you if there s a big change we can’t handle”
(parent of child with Spina Bifida) “they were amazed at the clinic that her neck and hips and legs..( range) …were so good!”
(parent of child w/ Legg Perthes) “the doctor said he might be afraid to try to walk or be too weak after all that time off his feet- she can’t believe he’s doing so well!”
Recent Updates
The TMR for Tots webinar was produced after approximately 1,000 hours of using TMR with children. Since that time some fine tuning has been done as parents have provided feedback as to what has been most helpful. The delivery of information to parents has been streamlined to accommodate time constraints in a therapists schedule, an evaluation form is being updated to provided information for the physician, and additional release positions have been added (eg: supine side bend).
The webinar information remains current. The only significant changes are:
1) It is easier and more effective to do one long slow gentle 3 min. hold rather than repositioning a child to do multiple 30 sec holds.
2) clarification of Side Bending is as follows: Sitting weight shift onto right ischial tuberosity with shoulders parallel to the floor shortens distance between left axilla and crest of left ilium = left side bend.
Written supplements are available for both past participants and those purchasing the webinar now to download.
In TMR 1 we will covering the basics of this approach as well as cover how it has been used with children with other diagnoses. Participants will be able to learn the releases and feel the effects in their own bodies in order to develop an understanding of how to modify and adapt treatments to the specific needs of the individual pediatric client.
Feel free to contact me by email or phone to discuss any questions or comments you might have about how TMR can be another wonderful tool to add to your toolbox. I look forward to hearing from you!
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