1. Dr. Caitlin Rutherford DAT, ATC Dr. Miguel Quintero DAT, ATC
The Assessment and Treatment of Bilateral Asymmetries: A Regional Interdependent Approach Utilizing A Quick, Robust Treatment
Dr. Caitlin Rutherford DAT, ATC
Dr. Miguel Quintero DAT, ATC

2. Conflict of Interest
“In compliance with continuing education requirements, all presenters must disclose any financial or other associations with companies to which they have a direct link and/or financial relationship that is related to the topic/content of their presentation.”

3. Objectives
After attending this lecture/lab, the attendees will be exposed to the Total Motion Release (TMR®) FAB 6 assessment process.
After attending this lecture/lab, the attendees will be exposed to the TMR® FAB 6 treatment process.
After attending this lecture/lab, the attendees will be introduced to current evidence on integrating TMR®.

4. Find A Painful or Restricted Movement

5. TMR® Score Sheet

6. Quick Treatment
Use the TMR® Score to subjectively grade both right and left side.
Identify a “Good Side.”
Perform 1 set of 10 on the “Good Side.”
Retest both sides and rescore.
Take note if the treatment made it better, worse, or same.
Step 1 on worksheet
If this worked, meaning it decreased your pain or increased your ROM then this worked via cross education

7. How Does This Work?
this works via cross education or formally known as bilateral transfer. This is a component of a regional interdependent paradigm known as total motion release

8. What is TMR®?
Restores and maintains allostasis by correcting bilateral ROM asymmetries (Dolanzo-Baker, totalmotionrelease.com).
Indirect treatment strategy that utilizes active movement subjectively rated by the patient based off of pain, speed, stability of movement.
Global approach to identify and restore bilateral asymmetries.
Treatments are performed to the patient’s self-reported “good side”.
Subjectively scored through six movements known as the FAB 6:
Arm raise (AR)
Arm press (AP)
Trunk twist (TT)
Leg raise (LR)
Sit to stand (STS)
Bent knee toe reach (BKTR)
TMR® is an assessment and treatment.
For those of you who got worse or stayed the same with the previous treatment, these next 6 exercises may help decrease your pain or increase ROM thru RI

9. TMR® FAB 6

10. Regional Interdependence
Theories of TMR®
Cross Education
Neural Coupling
Tensegrity
Mechano-
transduction
Regional Interdependence
TMR
Cross Education: formerly known as bilateral transfer.
Neural Coupling: UE works with the LE within the neural network. R & L
Tensegrity: Everything is connected within the body, specifically the fascial system (slings)
RI: more elaborate, current version of kinetic chain or jandas crossed syndrome

11. Theories Behind TMR® Cross education
Cross education, previously known as bilateral transfer, is a motor learning effect that takes place in the contralateral homologous muscle and is not dependent on muscle groups, age or gender (Lee & Carroll, 2007).
Unilateral resistance training may activate neural circuits and modify the efficacy of the motor pathway that project to the untrained limb.
Unilateral resistance training activates adaptations in the motor areas of the trained limb.
Neural coupling
Is the interaction of electrical signals generated by the nervous system in relation to other nervous tissue and/or nerve fibers within the body.
Example: Interaction of the neural network between the upper and lower limbs (Huang & Ferris, 2004, 2009).
homologous: same muscle opposite side

12. Theories Behind TMR® Mechanotransduction Tensegrity
The process of converting mechanical forces to biochemical activity.
Responses can be on the cellular level as well as the system/global level.
Forces are transmitted uniformly and instantaneously throughout the entire organism (Levin, 2002).
The body is comprised of a network of pre-tensed elements which pull towards the center of structures (Ingber, 2008).
Tensegrity leads to an efficient structure both on the cellular and the total organism (Chen and Ingber, 1999).
tensegrity example of fascial slings/tension are an example. force is being generated and transmitted across the entire body

13. Theories Behind TMR®
Regional Interdependence (RI)
The patient’s primary musculoskeletal symptoms may be directly or indirectly related to the impairments from body systems or segments, regardless of the proximity to the primary symptoms (Sueki et al., 2013; Sueki & Chaconas, 2011; Wainner et al., 2007).
Relevant contributors to musculoskeletal disorders may not be as straightforward as depicted in the biomedical model (Wainner et al., 2007).
Now that we discussed all these theories, some of you may be thinking how did TMR come about and how is it treating bilateral asymmetries?

14. Research in RI TMR® is inherently regional interdependent based.
Baseball pitchers with a bilateral total rotational of motion deficit greater than 5° are 2.5 times more likely to sustain a shoulder injury (Wilk et al, 2010).
Overhead athletes generate mechanical forces from various body segments within their kinetic chain; disruption along the body segments (kinetic chain) increases the athlete's risk for sustaining an injury to their most distal segment (Hoeven & Kibler, 2006).

15. TMR® - Background Tom Dalonzo-Baker MPT
Manual therapy based Physical Therapist
Background
Strain counterstrain
MDT McKenzie Method
Mulligan Concept
Logic for creating TMR®
Range of motion (ROM) asymmetries in various body segments was a prominent issue in his clinical practice.
Wanted to mimic activities of daily living.

16. Evolution of the TMR® System
Hips, knees, shoulders, and back were the four most common segments presenting with asymmetries.
FAB 5 introduced in 2002.
Walking, sitting, standing, going up and down stairs, and trunk rotation are activities of daily living that needed to be incorporated into TMR®.
Fundamental movement sequence of life needed to be included into TMR®; seated, standing, supine, crawling.
The system has evolved into the FAB 6.
The system gets more complex with multi-planar movements which can be performed in the standing, seated, and lying positions.
3 levels of the TMR® system.

17. Research on TMR® Upper Extremity
Gamma et al., 2018 & Gamma et al., 2014
n=20 in 2018
n=19 in 2014
Acute effects of IROM and EROM vs traditional baseball warm-up protocol
2 TMR® movements from the FAB 6
Trunk twist- 3 sets of 30 sec
Arm raise- 3 sets of 30 sec
19° and 13° increase in IR and ER
Anecdotal feedback on improved performance

18. Research on TMR® Upper Extremity Drake et al., 2016
Acute effects of IROM and EROM in swimmers between 2 and 6 motions of TMR®
Control group: TMR® assessment, no intervention (n=9)
2 TMR® group: Arm raise and trunk twist both 3 sets of 30 sec (n=9)
10° increase in IROM dominant arm; 14.5° non-dominant arm
2.5° increase in EROM dominant arm; 7° non-dominant arm
6 TMR® group: Entire FAB 6 for 3 sets of 30 sec (n=11)
11.5° increase in EROM dominant arm
Only had increases in EROM in dominant arm, whereas 2 TMR® group had increases in both IROM and EROM
7 of 11 participants reported trunk twist and bent knee toe reach to be there biggest area of difference

19. Research on TMR® Lower Extremity Archuleta et al., 2013
3 cross country runners complaining of hamstring tightness
1 TMR® movement from FAB 6
Trunk twist- 3 sets of 10
1 treatment per day over the course of 3 days
ASLR increased bilaterally ° average
Baker et al., 2015
Case report: 27 year-old former competitive speed walker
Week 1: forward flexion trunk twist for 1 set of 10 reps
Sit and reach 5cm increase; ASLR 31.5° average increase bilaterally
Week 2: Added instrument assisted soft tissue mobilization to the hamstrings (2 min.) and triceps surae (1 min.) to the treatment intervention
An additional 5cm increase in the sit and reach for a total of 10cm
An additional 7.5° average increase bilaterally for a total of 39°

20. Research on TMR®
The Effect of Contralateral Exercise on Patient Pain and Range of Motion
Fermin et al., 2018
“Will contralateral exercise decrease pain and increase ROM?”
1102 studies returned
5 were identified as best evidence on levels of evidence
2 of the 5 utilized TMR® as a treatment intervention
Remaining 3 utilized contralateral exercises
Clinical bottom line: contralateral exercises can be incorporated to increase a patient's ROM
ADD CAT

21. Research on TMR® Patient Reported Outcomes Patients: n=5 High school
Treatment Duration:
Average 4 tx with 1 F/U
Data:
4 acute; 1 chronic
Scores reflect average pre-treatment scores
Disablement in the Physically Active Scale (DPAS)
Numeric Pain Rating Scale (NPRS)
DPAS: MCID (minimum clinically important difference) acute 9; 6 chronic
NPRS: MCID 2 acute

22. Research on TMR® Patient Reported Outcomes Lower extremity injury: n=3
TT, LR, STS, BKTR
Upper extremity injury:
n=2
TT, AR, AP
Data:
Scores reflect average pre-treatment scores
Patient Specific Functional Scale (PSFS)
Lower Extremity Functional Scale (LEFS)
PSFS (inversely) 0 is worst and 10 is the best (patient picks 3 exercises to track over their tx intervention)
LEFS (inversely) 0 is worst and 100/80 is the best (20 activities on a Likert scale)

23. Lab Time
Take 5 minutes to get changed if necessary.

24. TMR® FAB 6
Arm raise, arm press, trunk twist, SLR, Sit to stand, and the BKTR

25. TMR® Arm Raise Assessment:
Sit upright with both feet flat on the floor.
Keeping your elbow straight, raise your arm in front of your body as high as you are able.
Keep your body and head in a still position throughout the motion.
Rate your left and right side using the TMR® Score.
What is your good side?
Step 2 on worksheet

26. TMR® Trunk Twist Assessment:
Sit upright without any support for your back and keep both feet flat on the floor.
Place both hand over your stomach.
Rotate towards one side as far as possible.
Rate your left and right side using the TMR® Score.
What is your good side?

27. TMR® Leg Raise Assessment:
Sit upright without any support for your back and keep both feet flat on the floor.
Straighten your leg with your knee fully extended.
While keeping your leg fully extended you’re going to bring your leg towards your stomach as far as possible.
Rate your left and right side using the TMR® Score.
What is your good side?

28. TMR® Sit to Stand Assessment:
Sit upright with both feet flat on the floor.
Lift one foot off the ground.
Your lifted foot may cross behind your planted foot.
Utilizing your planted foot, stand up and then sit back down in a controlled motion.
You may hold onto backrest to support your balance if needed.
Rate your left and right side using the TMR® Score.
What is your good side?
We recommend sitting sideways on your chair, so if you need to use the backrest for assistance you can.

29. TMR® Bent Knee Toe Reach
Assessment:
Stand in an upright position with both feet flat on the floor, shoulder with apart.
Lift one foot a few inches off the ground.
While keeping your foot off the ground, slowly bend your other knee, while lowering your body as far as possible.
While lowering your body, reach out as far as possible with your lifted foot.
You may hold onto backrest to support your balance if needed.
Rate your left and right side using the TMR® Score.
What is your good side?

30. TMR® Arm Press Assessment:
Stand in an upright position with both feet flat on the floor, shoulder width apart.
Facing the wall, place your hand flat on the wall with your elbow extended, similar to a one handed push-up.
You are going to step forward with your opposite leg.
As you step forward begin to bend your elbow, go as far as possible and then come back to your starting position.
Rate your left and right side using the TMR® Score.
What is your good side?
Step 3, arrange the order from highest to lowest difference

31. TMR® Treatment Treatment: Treat your good side. 2 set of 10 reps.
Reassess right and left side
Note any changes in TMR® Score.
TT, AR, AP, and LR can be done as a 30 second holds.
Make sure repetitions/holds are done towards the end ROM.
Don’t be picky about form.
Step 4 on worksheet
For those of you who stayed the same, maybe this treatment isn’t the most effective for the condition you have. You may need the multi planar FAB 6 movements or more sets and reps, etc. For those of you who got worse, sorry…. come see us after the course. But, for those of you who got better (show of hands) you may be wondering how did that work.

32. Summary
Identify a painful or restricted movement to track during the treatment process.
Rate it using the TMR® Score.
TMR® Assessment:
Rate your left and right side using the TMR® Score.
What is your good side?
TMR® Treatment:
Treat the “good side.”
May be performed in repetitions or holds.
Reassess your painful or restricted movement (from step 1).

33. Clinical Pearls Assessment: “Monkey see, monkey do”
Don’t be picky about form
Treatment:
Releasing any restriction that is inhibiting your patient from obtaining full end range of movement.
AR, TT, LR
Make adjustments to fit your patients needs
Avoid excessive repetitions
Prescribe home exercise
Robust treatment
Regional interdependent treatment
If time permits, do BOTT

35. References
Archuleta, I. Helvey, J. Baker, R. McDonald, N. (2013) The Acute Effects of Total Motion Release on lower extremity mobility deficits.
Baker RT, Nasypany AM Seegmiller JG. The reversal of chronnic musculoskeletal dysfunction and pain. Medicine and Science in Sports and Exercise, 2013; 45(5-Supplement), 718
Baker et al., (2015). A novel approach for the reversal of chronic apparent hamstring tightness: a case report. International Journal of Sports Physical Therapy, 10(5):723.
Chen, C. S., & Ingber, D. E. (1999). Tensegrity and mechanoregulation: from skeleton to cytoskeleton. Osteoarthritis and Cartilage, 7(1), 81–94.
Carroll, T. J., Riek, S., & Carson, R. G. (2002). The sites of neural adaptation induced by resistance training in humans. The Journal of physiology, 544(2),
Carroll, T., Herbert, R., Munn, J., Lee, M., & Gandevia, S. (2006). Contralateral effects of unilateral strength training: evidence and possible mechanisms. Journal Of Applied Physiology, 101(5),
Dalonzo-Baker, T. (2015). Where is the Research. Available from
Drake et al., (2016). Can Total Motion Release Increase Shoulder Range of Motion in Collegiate Swimmers? Journal of Sports Medicine and Allied Health Sciences: Official Journal of the Ohio Athletic Trainers Association, 2(1), 19.

36. References
Gamma, S. C., Baker, R. T., Iorio, S., Nasypany, A., & Seegmiller, J. G. (2014). A total motion release warm‐up improves dominant arm shoulder internal and external rotation in baseball players. International Journal of Sports Physical Therapy, 9(4), 509–517.
Huang, H. J., & Ferris, D. P. (2009). Upper and Lower Limb Muscle Activation Is Bidirectionally and Ipsilaterally Coupled. Medicine and Science in Sports and Exercise, 41(9), 1778–1789.
Fermin et al., (2018). The effect of contralateral exercise on patient ppain and range of motion. Journal of Sports Rehabiliation, 27,
Ingber, D.E., (2008a). Tensegrity and mechanotransduction. Journal of Bodywork and Movement Therapies, 12(3), 198–200. doi: /j.jbmt
Ingber, D.E., (2008b). Tensegrity-based mechanosensing from macro to micro. Progress in Biophysics and Molecular Biology, 97(2-3), 163–179.
Lee, M., & Carroll, T. J. (2007). Cross Education. Sports Medicine, 37(1), 1–14.
Levin, S. M. (2002). The tensegrity-truss as a model for spine mechanics: Biotensegrity. Journal of mechanics in medicine and biology, 2(03n04),

37. References
Sueki, D. G., & Chaconas, E. J. (2011). The effect of thoracic manipulation on shoulder pain: a regional interdependence model. Physical Therapy Reviews, 16(5), 399–408
Sueki, D. G., Cleland, J. A., & Wainner, R. S. (2013). A regional interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications. The Journal Of Manual & Manipulative Therapy, 21(2),
Wainner, R. S., Whitman, J. M., Cleland, J. A., & Flynn, T. W. (2007). Regional interdependence: a musculoskeletal examination model whose time has come. Journal of Orthopaedic & Sports Physical Therapy, 37(11),