We are on a campaign to stamp out torticollis. I have been visiting local pediatricians to update the doctors in an effort to encourage early screening in an attempt to begin intervention before more serious delays have a chance to develop. Many medical professionals have misconceptions about torticollis and it’s my mission to educate doctors so that we can nip this problem in the bud in order for children have the very best shot at developing their full movement potential.
In recent dialogue with several other therapists who also see many children with this issue the following list was developed:
5 MYTHS ABOUT TORTICOLLIS
1) Torticollis is localized issue
2) Torticollis does not cause developmental delays
3) A small tilt isn’t an issue – Child may outgrow
4) Therapy is not needed if the child just has flat spots on skull
5) Stretching is necessary to gain range of motion / Strengthening the weak side needs to be done in sidelying
It has been my experience that it is not a question of IF torticollis causes developmental delays but WHEN. Earlier intervention = Less need for intervention
1) Myth : Torticollis is a localized issue
Reality: Is any issue ever just localized? If you have a toothache doesn’t it effect other areas of your body. For every action there is an equal opposite reaction. The only question is where is the opposite reaction in the child’s body. Finding the root issue which may be mid-chest, pelvis, hyoid, or any other area not obviously related to the neck. When we use the FAB 7 to check the associated restrictions we see if we have indeed identified the chief culprit which more often than not isn’t the neck. Then when we treat the root issue results are faster and the problem stays corrected.
2) Myth: Torticollis doesn’t cause delays
Reality: In many programs a diagnosis of torticollis automatically qualifies a child for Early Intervention. They do not need the quantitative % delay as the problem is more qualitative. Just as in Down Syndrome children may not present with many delays initially, but we know that eventually predictable patterns will emerge. In tort we see the predictable patterns of delays in rolling ( child may only go one way and struggle with quality of rolling) delays in protective response ( one side holds elbow in stiff extension and falls more – usually right side), limited range in right shoulder flexion, unilateral pronation etc. not to mention dental implications of asymmetry which may affect speech and feeding as well as a distorted visual field rotated more to one side affecting spatial awareness.
3) Myth: A small % of tilt isn’t an issue
Reality: Imagine having to work all day long with your head tilted 10 degrees to the side. How would that effect your overall performance? What if you did not yet have good balance skills or had not yet learned to sit up or walk? How would this impact your achievement of these skills? How would this impact your handwriting skills? If this posture became hard wired into your system what would be the effect with your growth spurt at puberty. Might this be the cause of idiopathic scoliosis?
4) Myth: Therapy is not needed if a child just has flat area on the skull.
Reality: Asymmetry in skull shape reinforces asymmetry in neck position causing rotation more to one side. This in turn places the muscles that are in a shortened position to develop shortening in the fascia and ultimately developing restrictions in movement.
These restrictions have associated restrictions elsewhere in the body ( the equal opposite reactions) causing total body issues.
5) Myth: (a) Stretching in needed to gain length. (b) Strengthening in Sidelying needed to gain strength in the over lengthened lateral neck muscles.
Reality: (a)There are volumes of research on the need to stretch muscles for prolonged intervals (many hours over many days) to gain length in muscles (eg: gastrocs with serial casting) How then are we supposed to lengthen a SCM with brief stretches? There is also decades of treatment using osteopathic techniques to shorten muscles to lengthen fascia. What are we trying to lengthen in torticollis? If we can do it a pain free way with shortening and it works, why would we want to stretch.
( b) Babies don’t come with owners manuals to show parents how to hold their children in a horizontal sidelying position to get strong necks. If we first get the body under the neck in neutral alignment (using the FAB 7 to address the total child) the baby will automatically start to try to right their head in a neutral position. Using therapeutic play activities in natural positions fits into daily routines and develops strength though out the course of the child’s day with greater frequency and effectiveness.
The doctors I have met have been most receptive to a quick visit to show them
before and after pictures of several children with torticollis who received treatment just using TMR methods. Showing them a snapshot of the difference in ability to side bend right vs left and do lower twist right vs left has educated them in the importance of looking at these motions as part of their own screening during early well visits. I am hopeful that the children picked up sooner will need less intervention and be able to develop motor skills with greater ease and ability.
(TMR meets NDT) - Toddler with G-Tube and Weak Abdominals
The issue:
Recently evaluated a child with a gait delay who still had a wide based gait and fell easily. She had a feeding tube and had over lengthened abdominals. There was also concern that the child was sore at the tube site and they did not want to irritate the area.
The observation and testing:
There were no initial obvious differences in the child’s posture other then an exaggerated lordosis and wide based gait. When we tested the FAB7 there was an extreme difference in her twists. Upper rotation to the right was severely limited in sitting (lacked 75 % of motion) and most evident in mid to upper trunk. Lower rotation was only 1/3 to the left which corresponded to the upper restriction. I could feel a tight pull of fascia between her right ribs and her left ASIS which was restricting both her ability to rotate or activate her abdominals to anchor her ribs so that the ribs were pulled up and flaring.
The limitation in movement:
Limited mobility in her obliques surrounding the tube site. She could neither contract the over lengthened muscles, nor relax to allow them to lengthen to fully rotate her trunk.
The TMR treatment:
While we spent a few minutes discussing how treating by shortening an area can lengthen something tight instead of stretching. I showed mother how to do a twist hand over hand on the child. Mother immediately noted a huge improvement as the child’s rotation tripled in the next 10 min. Mom happy with the plan and was quickly onboard, because the child was comfortable.
Add NDT:
Here’s where using traditional techniques on top of the TMR framework has worked the best: Using NDT techniques to anchor her lower ribs with my palm I was able to draw her obliques into an even shorter position in flexion and rotation to the side of ease and then use my fingertips to facilitate her abs. Now we could get her muscles into a position with the shorter length needed to activate them to jump start her on core strength. I will follow a similar sequence in future visits as we assess need to work on her gluts etc.
The Analysis & Plan:
Since the rotation was in the direction of ease where her G-tube was inserted, there was no stress on tissues. Had we gone the hard way there would have been painful pulling, but this is not part of the TMR plan. The child was comfortable to continue to work on strength with the home program I then developed for the family. We started them with reverse oblique crunches in a shortened range to the side of ease. Parents saw the immediate change in mobility are delighted that they can something concrete to work on to make her strong themselves that does not cause their child further pain. First visit and we are on our way to correcting abdominal weakness that is limiting her core control needed for safe and narrow based gait!
Where do you begin with a Teen who was a Shaken Baby?
The challenge: When I received a referral to see a young man who had profound issues as a result of being a Shaken Baby, I was excited to see how I would be able to help him now that TMR is a big part of my toolbox. I had treated him from preschool up to age 12 and was saddened to see his mobility decrease month by month. Despite excellent follow through with nurses and caregivers, the effects of gravity and limited active control pulled him more and more into a windswept, kyphotic, sacral sitting position. Even with an adapted wheelchair with a split seat to accommodate a severe pelvic obliquity, he now a required pillow to prop up his right side so that the lateral support didn’t dig into his ribs. His hip dislocated and hamstrings shortened. He continued to receive therapy at a new school for the last few years, but his physical issues just got worse. There was no seated position that was comfortable and he was now spending more time in bed which was also becoming less comfortable. When his family found out I was doing something new, they asked for a referral so that we could do TMR. This month a PT totally new to TMR contacted me to inquire about how the method might help her pediatric patients. She has not taken a course yet, but after our conversation and checking out the videos on this website she was able to help her patients the very next day. Here’s her report:
The system:
We began by identifying the issue which was the family’s concern that he is uncomfortable in any seating system which made feeding a challenge. He was observed draped over a pillow in an attempt to prop up his right side. Since he has flexion contractures in his elbows and wrists he was unable to use his arms for support With very poor head control and his neck hyperextended or his chin resting on his chest, he
was unable to maintain positioning on a head rest so had to have his head manually supported to be fed.
Next we tested for mobility restrictions using the FAB7. It was easy to identify some of the areas. He had no side bending to the left as his weight was almost totally on the left ischial tuberosity which made it the top ranking motion. Both hamstrings and ankles were tight, but one was better. The second ranking motion was the trunk twist only about ¼ of the way to the left. Arm raise was third ranking being limited to 40 degrees.
The treatment:
Because of the severity of his restrictions and multiple medical issues it was necessary tomodify all of the motions to match the positions of ease for this patient. We supported him sitting on a stool in front of me as he rested backward against my chest. With my arms around his chest I was able to rotate my body to the left and right to help him rotate his. Since he is unable to communicate other than facial expression or by crying or cooing it was important to monitor his reaction to be sure that he was comfortable. The beauty of TMR is that he was comfortable to move into the positions of ease.
The result:
As we proceeded to do the motions he relaxed more and more. We could see his wonderful expressions as he was given support to move and it was a joy to hear him cooing with delight as he enjoyed the movements! While he is unable to vocalize he was able to take the deep inspiration and then let out a huge sigh. I could feel his entire body let go and finally relax. As each release was performed he moved deeper and deeper into each motion and I could feel him begin to assist more with the motion as he became more active. After several repetitions we rechecked his motions. His arm raise and twist on the bad side more than doubled and he was beginning to extend his spine and bear weight on the right ischial tuberosity !
3rd Party – Functional Outcomes:
How do we justify therapy to 3rd parties with such a profound situation after he has received years of therapy for this diagnosis?
Goals include the following: improvement in range for his nurses to perform bathing and personal care.(this was seen immediately in left arm raise and hip abduction), improved trunk extension for rib expansion (hx of pneumonia related to scoloiosis, kyphotic posture and tight pecs), improved ability to sit upright to attend to tasks in school and to keep his head more in midline to for safer feeding, improved mobility to roll in bed., improved physiological status, improved sitting posture to prevent possible skin breakdown associated with pelvic obliquity. Ultimately I hope to see him in a more comfortable wheelchair with less need for expensive adaptive components.
My goal for him is to see him comfortable and decrease the effects of this terrible brain trauma by helping him find ways to be positioned with more comfort and ease. What’s the best part of bringing TMR to this family? The joy that the gift of movement has given to this young man!
Case Studies
“I was able to try TMR (or at least what I think are some TMR principles) with a kiddo this evening and I am a little blown away. This little guy is 2 1/2 years old. He is extremely flexed at the hips with a history of torticollis. I have been working with him for 3 months and we have been making nice progress. I incorporated moving his body the way he wanted to go into our activities and he seemed to change before our eyes. After 5-10 minutes of following his body, he began standing more erect. He was able to achieve active hip extension in a gait trainer and even more astounding to me and his parents, he attempted to take steps with one hand-hold assist and holding onto a support surface with the other hand. He made it about 10'. We also worked on stairs and he spontaneously attempted to climb up a plastic slide (not on the steps but the actual slide). What I found so exciting about this is the amount of lower extremity range he needed to bring his foot up, weight shift, push and bring his other foot up. Of course, his feet slid back down the slide but he handled the movement without falling, supporting his body with his arms, and kept trying to get up the slide on his feet. I also noticed when he sat, he was still posteriorly tilted at the pelvis but not nearly as much as he had been. One of his legs was almost straight out and the other is still internally rotated and flexed. We still have work to do, obviously but his whole level of activity kicked up a notch and what he was willing to do on his own was significantly more than usual.”
And the next day:
“Today I saw a lot of kiddos who are more involved…It was quite fascinating. I realize I do not have a clue what I am doing but letting the body go in the direction it wants to and then moving back into the range of motion I would like seemed to really work with some of the kiddos. A 15 year old girl with spastic quadriplegia was able to achieve some nice sitting on her ischial tuberosities instead of her low back. In addition, when we got in her hands-free walker, she was really able to engage her lower extremities and pick up her feet. Her right leg moved better than her left as this leg was the one I had spent more time working with.”
“A 6 year old I see who suffered a TBI at 6 months also responded well. She was able to prop sit near the end of the session independently x 5 minutes. She has NEVER been able to prop sit.”
“I am convinced that the simpler an idea, the more likely it is to be effective. I just find when I work with a child's CNS, I get much farther than when I work against it.”
“I watched the webinar this morning/afternoon. It made a lot of sense for me. I tend to resist 'forms' but I understand why you use it. None of the motions you demonstrated are foreign to me, just the concept of doing them into the 'bad' position. …one release can drive all the releases as you explained with the little girl with CP. It is back to the concept that everything is connected and a change in one place creates a change in another place… What is needed will always be dictated by the child.”
Note from Susan: Excited about these results this therapist was hpapy to have us share this report with you. Just applying the basic ideas of allowing the body to move to shorten the mobility restriction and focus on using the good side to develop strength produced results which have become typical in my practice. Seeing these results with her patients she can’t wait to take the seminar to see how the FAB 7 will help create a systematic care plan to help them even more!
We have added locations for upcoming pediatric seminars including Philadelphia, Baltimore, Raleigh and Minneapolis. (Note the Baltimore site is a Friday-Saturday seminar while the others are Saturday-Sunday.) Looking forward to having you join us! Feel free to contact me at 717 309-1354.
New Challenge - Child with severe tactile defensiveness
Have you ever seen a child that would not let you touch them or even get near them? How would you assess them? What would you do to treat them? Where to begin?!?
Recently a child was referred for PT because at 14 months she was unable to transfer out of a long sitting position. Mother reported that she had extreme sensitivity to touch and would scream if anyone tried to assist her to move. She would only sit in mother’s lap and would cry if approached. In addition she was easily startled and would stiffen and extend her extremities if excited in any way. One of her siblings has a diagnosis on the Autistic Spectrum. While the family is experienced in dealing with sensory issues, they were at a loss as to how to help this child. At this time they only want PT services. Their functional outcome is to provide her with independent mobility. What to do?!?!?
In my pre-TMR days it would have been more than a challenge. Frankly I don’t know where we would have begun. Now with TMR I could confidently reassure mother that we had a plan and were ready to begin. Here’s what worked:
Since the child would scream and stiffen if anyone was close to her, I used my therapy doll to show mother the TMR FAB7 (pediatric FAB5.) First mother was shown how to figure out what the good side was on herself. While I demonstrated each motion on the doll, mother then held the child and moved her through the motions. This was a more subtle difference than a big restriction of range of motion typically seen with a diagnosis such as torticollis, but nevertheless there was a good side to each motion. There is always a good side. Mother was able to determine which ways were the directions of ease and recorded these.
After the directions of ease were determined we ranked them and placed the child in a therapeutic position that included these components: Left side bend, Left upper trunk twist, Right lower trunk twist, slight right sit to stand etc. . The child then was able to relax and snuggle into a comfortable supported position that her body was happy to assume. This opened the door to introducing the concept of trunk rotation to the child who typically only sat bolt upright in a long sitting position. Gradually she was able to have mother introduce a partial transition out of sit toward hand and knees by first twisting to the good side to place her hands on and elevated surface and then the floor.
In the following visits the child was treated using the same sequence with extensive positioning in the therapeutic position followed by assisted movement in the direction of ease expanding the zone into which she would explore. The bonus was that after several visits it became possible to put the child into this therapeutic position and then transfer her into my lap! Relaxing this way seemed to disarm her tendency to react and stiffen!
She now allows me to handle her and we alternate between parent and therapist to guide the family with developmental exercises. At our last visit we were able to continue expanding her world as she allowed me to help her transfer from sit to all 4’s to kneel to pull to stand. Each step was carefully selected using the step by step sequential system which TMR offers. I’m so very thankful to now have a most effective system to be able to offer this family assistance. For further information please feel free to email me at susblum@aol.com or call (717) 309-1354.
More Case Studies
Just got to love that turtle guy (see Tom’s 7/09 blog.) Was trying to explain to another therapist how I evaluate all my pediatric clients w/ TMR regardless of diagnosis. They say a picture is worth a thousand words…. Well seeing the Turtle Guy on the video gave me some wonderful insight into how I believe TMR helped one of my little patients achieve more than I would have ever expected. It also helped to be able to explain how we can treat the total child in a logical sequence.
Here’s what’s been happening with one very special little boy. He had been receiving PT for 2 months before I took TMR1. After returning home, I immediately began to look at him from an entirely new focus. At that time he was 14 months old. He had spend an extended time in the NICU following a prolonged series of medical complication resulting from birth at 31 weeks gestation. Diagnosis was given as PVL w/ left hemiparesis. He kept his left hand in a fist with his thumb tightly flexed in the palm, his left hip was internally rotated and lacked 30 degrees external rotation, he was dominated by extension and arched his back when exerting effort with a motor task. When he tried to crawl it was with a tightly flexed left upper extremity..
Parents were completely onboard with TMR when they saw immediate changes. Mother took ideas as suggested and incorporated them into his play activities. My application of TMR was very basic and consisted of: 1) Analyzing which side L vs R had better range of motion 2) Using the better side in the FAB5 position to improve range of motion in the bad side followed by 3) Using the better side as the model to help the child achieve success in a motor task. An example of this was to have him sit and do twists to the left followed by active reaching to the left. While I could see the connection between tight soft tissue at the waist limiting arm raises, most of my application was based on understanding his progress in terms of EG: Right arm vs. Left arm.
After TMR 2 and 3 we switched to working the Upper Body to fix the Lower Body,
Mom kept up UE exercises even though UE control was now good bilaterally with the exception of end range shoulder motion.. He had been doing so well with the basics that his parents were excited that I was going to TMR-2. The family was faithfully doing the FAB5 focusing on whatever was the worst at that point in time. He could stand with his feet in neutral and now had functional range and strength in the left upper extremity.
Although he was now walking independently and had good range in the left hip, he continued to internally rotate his hip and on occasion would trip. We ramped up strength exercises having him do step aerobics on the right (good) side. Mother now having a better understanding that opposite could also be Upper vs Lower or RUE vs LUE mother started experimenting with upper extremity games. She discovered that he enjoyed using a bat with a wiffle ball suspended from overhead at the height where he had to reach to get a good right arm raise with effort while the left hand only grasped the base of the bat. Within a short time control in his left lower extremity control kicked in! Now he is learning to jump and enjoys climbing on all kinds of playground apparatus.
In retrospect Turtle Guy makes these developments make sense. (I’m the type that has enough faith to know that when I hit the button the TV will go on, but still want to understand how the set works) Once we show parents how to help their children achieve symmetrical mobility, using the Turtle Guy model we can help them progress to gain strength using the whole body when we understand how an arm raise is connected to hip control. Using the FAB 5 to search for the worst restrictions is the start of all my evaluations. Building on the mobility with strengthening activities treats the total child.
I believe that we have barely begun to scratch the surface to discover the potential of this approach.
18 month old child with genu varum and asymmetrical toe-in gait
One year ago an 18 month old girl was referred to PT because of parents concern about frequent falling. Parents were requesting shoe inserts or braces to correct a “severe in toed gait and bowed legs.” The child had reportedly been walking since her first birthday. I observed that she would walk about 5-8 feet and then trip over her feet. After 6 months of experience walking she could still only walk a few feet before falling down. Her left foot turned in approximately 45 degrees and the right 60 degrees intermittently up to almost 90 degrees causing her toes continuously trip each other.
When we checked the FAB5 the most remarkable differences were in Leg Lift and Trunk Twist. In addition to her Leg Lift being limited on the right I noted that it was more limited when her hip was in an externally rotated position. She had excessive drag in the soft tissues effecting the right hamstrings especially medial. The right and left sides were compared to determine the amount of hip abduction which gave the greatest difference right and left and this was recorded on the FAB5 form.
Due to a language barrier an interpreter was needed to communicate instructions to the family. Since I use demonstration on the parent as part of their instructions in the home program, there was minimal challenge despite the language difference. The language of movement is universal!
Dad quickly grasped the concept of treating the good side and was most enthusiastic about implementing the program. He was happy to be reassured that physiologic genu varum is a common self limiting condition in toddlers, and appreciated my concern for the unilateral problem with the more severe in toeing on the right as being the child’s main issue. The home program was to hold the child and help guide her to twist to the good side followed by play activities within the new available range. The modified Leg Lift was used on the left leg with her left (good) hip in external rotation.
At the next visit the child had significant improvement in Trunk Twist and moderate in Leg Lift. It was noted that she was unable to use her right lower extremity to go up a step and when she tried to go up, her right foot turned in a full 90 degrees. Despite the right side being the “problem side” her Sit to Stand was better on the right. All other motions and differences were demonstrated to the parents and standing Sit to Stand was added to the home program. This session was recorded on video and we had the interpreter repeat the key cues in their language while I demonstrated each of the FAB 5 motions so that the parents could have this available for future reference. The parents demonstrated their ability to follow through with the program and the special instructor was present to learn how to position the child to use the range EG: try to touch a balloon suspended from overhead with toe during Leg Lift. Brainstorming was done to discuss activities to reinforce and utilize improvement achieved through her TMR program.
Because of family schedule, availability of support staff to reinforce instructions, and clearly defined consistent limitations in movement, the next visit was scheduled for 8 weeks. Parents were to recheck other FAB5 motions and call therapist if an additional visit was required prior to the next visit. Family implementation of strategies was excellent so that the child only needed to be seen every 8 weeks. She made rapid gains as her toe in gait decreased and her right forefoot posture improved. 12 months from the initial visit she now stood with both feet in a symmetrical neutral position, she could now run with ease and was beginning to jump. Genu Varum was resolving as expected and since no further therapy was needed she was discharged from care.
CASE STUDY - PART 2
Now at 18 ½ months the child introduced last month has made significant progress. Previously she struggled and fell each time she tried to pull to stand. She was extremely fussy and frustrated by repeated failure to be able to keep up with her twin.
Initially she pulled her heels off the floor and only would briefly bear weight on the balls of her feet as she tried to transition into extreme hyper plantar flexion to bear weight on the dorsal surface. As she tried to plantar flex rolling over the 5th toe on the left and the 1st toe on the right. Her hips were in extreme abduction and she was unable to pull to stand without falling to one side.
Observing her in play at the next visit we continued to see the asymmetry medial lateral hind foot position. While she could pull to stand safely and she now stood with both heels on the floor, the left foot was supinated and the right foot pronated! After documenting subjective information with parents and briefly observing the child in play we returned to the FAB 5 as the next step in her visit. Her Twist and Arm Reach had improved significantly so that the right and left sides were more balanced. When doing a standing assisted Sit to Stand she could do a deeper squat on the good side and there was less posturing of her arms to keep her balance on the bad side.. Both of these observations were recorded to reflect the improved control achieved with this exercise. Side bend and Leg Lift which were identified last visit now ranked highest (had the greater difference between right and left sides.) From this data the home program for the next week was developed. Parents were excited about progress and had developed play activities to incorporate these therapeutic positions into her daily routines. These were reviewed to add or fine tune facilitation techniques to enhance her body awareness for further improvement in motor control.
Great news 2 weeks later at our next visit! Our child not only began to cruise had been taking independent steps for 2 days! She was observed walking 10 feet with a wide based gait and now had the coordination and speed to keep up with her twin in play. The supination/ pronation issues were still present and she walked with her right navicular reaching for the floor and the left forefoot adducted with toes curled for stability.
Once again the FAB 5 were assessed and ranked. A therapy ball was introduced to work on side bending both at session and home program. After treatment of the high ranking positions, she was observed standing and walking further with her feet in more neutral alignment and with less toe curling!
At the next visit one week later she was now walking in and outdoors on levels, inclines and uneven surfaces for an unlimited distance! Very little toe was curling noted. The excessively wide base and medial/ lateral issues were still of some concern. Along with dramatic improvement in motor performance was a change in her behavior. She was no longer the irritable fussy child and was observed happily playing as she could keep up with her sibling. Writer and parents reflect on possibility that delay in walking and asymmetries may have been related to soft tissue shortening developed due to limited mobility in womb due to multiple birth pregnancy.
Her FAB5 program fine tuned and play activities were modified in home program to reflect current ranking. Instruction was provided to parents to continue do high ranking positions several times a day and lower ranking once a day. They demonstrated their ability to rank all of the FAB 5 and implement therapeutic positions and play activities as instructed. Parents and writer agree that since they are comfortable with current program visit frequency can be decreased to every other week at this time. Parents report that they are delighted because they never expected such rapid progress! (Neither would I have before TMR!)
CASE STUDY - PART 1
Here’s a challenging case that I recently started seeing. A 17 month old child was pulling up at furniture with an extremely wide base stance. Her feet were way past her shoulders almost in a split and she was trying to weight bear on the dorsal surface of her feet! When she would try to stand she would plantar flex on the left , roll over the 5th toe onto the lateral aspect of her left foot and the 1st toe on the medial aspect She was unable to balance holding on in this posture which was putting extreme force on her ankles. Because her twin had been already walking independently for 3 months, she was getting very frustrated. When she repeatedly tried to cruise she couldn’t balance to initiate the activity and fell. The parents reported this happened continuously as she was on a mission to keep up with her sibling. She appeared to be very frustrated and unhappy with each failed attempt. There were no other concerns and nothing else was identified in her history and evaluation.
Where to begin? That was easy - as always the FAB 5.
After taking the history and observing the child in motor play we did a TMR evaluation. While she did not have any severe limitations, there was moderate asymmetry in trunk twist and arm raise range both to the left. When she stood up by herself she would stand on her toes and try to stand on the tops of her feet to stabilize and then fall down. She resisted any attempts for parent or myself to help her stand up so we only checked sit to stand in supine this visit. We instructed the family to do the twists for her home program and therapeutic positioning using the arm raise to reach for a toy.
Upon return to the home we noted that since parents had done the twists and arm raise there was excellent improvement in her trunk movement symmetry. We now discovered that when sit to stand in assisted standing was tested, she had better control on the right side. Parents were taught to do assisted sit to stand on the good side through a small range. To engage the child we made it a play activity as if she was riding a pony. She was so used to trying to initiate stand by dorsiflexion, the parents were shown how to reinforce flat stable foot position some facilitation techniques. Body awareness techniques were used to reinforce her use of her new found movements.
The next visit twisting was now more improved. Her parents reported they were pleased that they didn’t need to provide as much hands on support. Since we always check the FAB5 each visit, we now identified some small issues with side bend and leg lift. (This is to be expected as it is part of fine tuning.) She was able to bend and straighten her knee to sit to stand through a much greater range. After doing the sit to stands in therapy we progressed to doing weight shifts by dancing in place with support under the arms. Parents were following through with TMR releases, sit to stand for strength. After doing the sit to stand assisted bouncing and dancing in place was added to her home program to reinforce the control achieved with the TMR techniques.
Observing this child she now appears happier and more relaxed and the frustration is gone. The parents report they are very pleased with her excellent progress.
Next month we will have an update. Keep posted for more info!
I believe that we have barely begun to scratch the surface to discover the potential of this approach.
