TAMO Terapija PDF
TAMO Terapija PDF
TAMO Terapija PDF
Purpose: The purpose of this article is to describe the relationship between specific concepts of dynamic
theories and specific Tscharnuter Akademie for Movement Organization (TAMO) therapy principles. Key
Points: Theories of dynamic perception, such as functional coupling between organism and environment,
active pick-up of task-specific information, functional coupling between perception and action are empha-
sized. Principles of TAMO examination and treatment apply theoretical concepts of nonlinear, reciprocal
interactions between organism and environment, information-based perception and action, internal and
external forces acting on the body. To determine skill levels, TAMO focuses on self-produced actions, their
adaptability to diverse situations, and the active and selective pick-up of task-specific information. Without
moving the patient, the therapist provides task-specific information and changes the existing force distribu-
tion through a gentle, task-specific loading input; thus patients are challenged to actively reorganize to new
situations. The variability associated with exploring available movement possibilities teaches patients which
perceptual-motor aspects need to be monitored. Subsequently, these rules of coordination can be spontane-
ously generalized to a variety of similar situations. (Pediatr Phys Ther 2002;14:29 –37) Key words: perception
and action, motor control, movement disorders, movement therapy
Pediatric Physical Therapy Applying Dynamic Theory Concepts According to TAMO Therapy 29
higher-level brain centers were not controlling the domi- tions, but to the ability to work with internal and external
nating influence of more primitive CNS structures. A hier- forces that act on the body at each moment. The various
archical structure also implies that the development of mo- skill levels of these interactions are continuously explored
tor skills and the recovery after a CNS insult occur in a in TAMO. Stages of skill development focus on aspects that
predetermined sequence of developmental milestones and are different from traditional descriptions of sensorimotor
their underlying movement patterns. This information led development.
therapists to focus primarily on specific or standardized Clinical research in using TAMO therapy is in
motor patterns and on the sequencing of their appearance. progress. One research project addressed excessive foot
Properly applied specific sensory stimuli were used to re- pronation in teenagers and adults.7 Measures of force pro-
organize motor output2 and to affect CNS structures. Tech- duction during gait, calcaneal angle measurements and
niques to inhibit abnormal movements and to facilitate arch width measurements showed that all 12 participants
normal movements were applied in treatment. Specific improved significantly from pre to post tests after two or
sensory stimuli were also used to normalize tonus. The three TAMO treatment sessions. Most of the improvements
assumption was that normal tonus would result in normal were maintained after one month. Additional clinical re-
movements. In time, therapists noticed that the movement search and case studies are certainly needed to gain more
patterns that were facilitated during treatment were not insight into the applicability of TAMO therapy.
applied in self-generated functional activities. In addition,
many theoretical concepts underlying traditional therapy PURPOSE
principles were put into question by newer insights in neu- The purpose of this article is to demonstrate the ap-
rophysiology and in the movement sciences. Conse- plication of theoretical concepts of dynamic perception8 –12
quently, many therapists started to modify their therapy to specific TAMO therapy principles. By taking a functional
techniques to achieve better results. rather than neurophysiological approach to perception,
The drastic changes in theoretical thinking challenge the theory of dynamic perception offers very valuable con-
clinicians to find useful clinical applications of current the- cepts to clinicians. James Gibson first proposed novel as-
oretical concepts. It seems very difficult—if not impossi- sumptions about perception8 more than 40 years ago. Gib-
ble—to attach new theories to therapy principles that arose son offered an ecological perspective to dynamic perception
from very different theoretical concepts. Dynamic theo- where the function of perception is to link the organism
ries3,4 present concepts that have proven very useful to the with the environment. The resulting reciprocity between
clinical work of this author. Dynamic theories acknowl- living systems and their environment yields perceptual
edge that biological systems are complex, and that many guidance of actions. Thus, actions spontaneously adapt to
components of the organism, environment, and task inter- new and diverse situations.9 Gibson’s concepts are still sci-
act to produce motor behavior. Biological systems are also entifically valid today and are the topic of numerous mod-
seen as nonlinear; a minor change in initial conditions may ern research projects.9 –13
lead to a significant, abrupt change of behavior. Timing and Major concepts of dynamic perception theory that
form of such changes are not fully predictable due to the have proven clinically important to TAMO therapy in-
complexity of the system. Finally, biological systems con- clude, 1) the functional coupling between the organism
stantly interact with the environment creating a state of and the environment, 2) the active pick-up of task-specific
nonequilibrium, which activates the system. These observa- information, and 3) the functional coupling between per-
tions allow the clinician to achieve a system wide re-orga- ception and action. Each of these three concepts is intro-
nization in response to a selective change of important duced with a description of the most important theoretical
external factors. These concepts are applied in TAMO aspects. Each theoretical section is followed by a discus-
therapy. sion of the application to TAMO therapy principles. Ther-
TAMO is a new therapy approach that was developed apy principles are based on the clinical experience of the
on the basis of modern theories and on the clinical experi- author. Some figures are used to highlight therapy
ences of this author.5,6 After having taught Neuro-Develop- concepts.
mental Treatment (NDT) for more than 13 years, the treat-
ment principles of the author were no longer compatible FUNCTIONAL COUPLING BETWEEN ORGANISM
with the fundamental principles of NDT. These new clini- AND ENVIRONMENT
cal concepts needed to be referred to by a new name. In
1990, TAMO, the abbreviation for Tscharnuter Akademie Theory
for Movement Organization, was chosen. Since 1991, Dynamic and traditional theories of motor control dif-
TAMO therapy has been taught at various universities in fer in their interpretation of the functional relation between
the USA and in continuing education courses throughout the organism and its environment. Traditional theories
this country and abroad. In TAMO, the CNS is no longer suggest that the environment serves as a stimulus to acti-
seen as the only factor determining motor outcome. In- vate appropriate, preordained motor reactions, which are
stead, the focus shifts to the interaction between many controlled by the CNS.2 Dynamic theories describe motor
sub-systems including external factors. Motor control is behavior as the result of the reciprocal interactions between
not linked to specific patterns or movement configura- many subsystems (components) of the organism and the
environment.3,4 From a dynamic viewpoint, motor behav- degree movements can be adapted to existing, natural sit-
ior is controlled by the organism-environment system.8,9 uations. Adaptive behavior is inherently not standardized
Dynamic perception theory suggests that the organ- but variable. Adaptability of self-initiated movements to
ism is optimally attuned and adapted to the environmental diverse situations is a significant functional skill. Insuffi-
niche in which it evolved.8,14 For function, the organism cient adaptability of spontaneous behavior limits func-
and environment form one system that is constrained to tional skills.
interact in a coupled mode.12 They affect each other. The For example, a patient may seek postural stability by
reciprocal interactions between organism and environ- statically keeping the pelvis in an anterior tilt and the spine
ment adhere to laws of dynamics.15 Yet, due to the enor- in extension. When creeping with such a static posture, the
mous complexity of biological systems, it is impossible to progressing leg pulls the pelvis and spine sideways with
predict the exact contribution of each component. The ex- little motion in the hip joints. As a result, steps are very
act conditions of the environment and organism differ even short (Fig. 1A). After a one-hour treatment session, this
in similar situations; consequently, each situation de- 18-month-old child is very capable of spontaneously pro-
mands unique movement patterns for optimal perfor- ducing well-adapted creeping patterns. He dynamically
mance. Many skillful movements are new in their detailed stabilizes the legs while pelvis and trunk move in perfect
structure.14 This implies that exact movement patterns may alignment. The weight-bearing hip pushes into extension,
not be stored in fixed motor programs for later recall. Since leading to long steps as the distance between both knees
actions cannot be seen in isolation from the situation in indicates (Fig. 1B). The treatment did not address directly
which they take place, the contribution of the CNS to mo- motor patterns of creeping. The therapist selected to work
tor control must occur in collaboration with peripheral and on the adaptability of the legs to the support surface in
external forces and influences. External and peripheral various positions. She assumed that learning to dynami-
forces have a considerable influence on actions.14 Actions cally stabilize against the support surface and to push off it
are defined as goal directed movements. Concepts associ- in a variety of patterns would improve performance. Ther-
ated with the functional coupling between organism and apy took place in dynamic sitting, supported standing and
the environment have a profound impact on TAMO ther- during transitions between sit to quadruped and squat po-
apy principles. sitions. Gentle therapeutic input gradually modified the
loading pattern of the legs in these situations. The child
Application to TAMO Therapy Principles was playing during these activities and thus he determined
Spontaneous adaptability of self-organized motor the movement excursions. The therapist’s loading vector
patterns. The interactions between the organism and the was dynamically adapted to various phases of his move-
environment are primarily expressed in self-organized mo- ments. Yet, the handling input was so gentle that it did not
tor patterns. Self-organized actions demonstrate to what move the child; instead, the therapist waited for the child to
Pediatric Physical Therapy Applying Dynamic Theory Concepts According to TAMO Therapy 31
adapt to the modified pressure distribution at the support The information of a stimulus differs from the sensation of
surface contact. Although the child’s adaptations were not a stimulus. Research in early perception has shown a col-
perfect in the beginning, the behavior was no longer static laborative interaction between all sensory systems and the
and adaptations improved with repetitions. equipotentiality of different types of information.15 Major
The opportunity to explore various adaptations in a parts of such information are therefore redundant. It is
safe situation leads to discover a variety of movement pos- important to realize that task-specific positional and veloc-
sibilities for similar situations. Static behavior thus changes ity references are not restricted to one specific sensory
to dynamic and variable patterns. The efficiency of such channel.16
movements varies; some movement attempts may be un- Perceptual systems attend preferably to dynamic
successful. But all of them are important to learn what events, because they provide more information than static
works and what does not work. The therapist never inhib- situations. Meaningful information lies in the dynamic
its nor corrects motor components that may interfere with transition.15 This allows even very young infants to capture
more skillful movements. Instead, it is expected that the
rules of pattern change; consequently infants perceive
patient discover different, more adaptable patterns in re-
moving objects or persons as unified and coherent events.15
sponse to the therapist’s loading input. The therapist’s
Size and form of objects and persons remain constant for
loading input changes the force distribution on the body as
the observer under varying conditions of illumination,
naturally fits the situation. This way, situations are pre-
sented that the patient cannot yet create and consequently viewing angle or distance.15 This indicates that invariant
has not yet explored. A successful re-organization does not properties are recognized in spatiotemporal transitions,
occur when the therapist’s loading input does not fit the which may explain why newborns recognize any human
situation or when the activity is too difficult for the patient. face in various situations.
Changing conditions of task and environment further To perform a successful action, relations between ob-
encourage exploratory actions. Spontaneous, self-orga- jects and subjects must be perceived prospectively.10 We
nized actions range from active adaptations in natural care need to know in advance how the situation will unfold
taking situations to independent movements. Some skills while we move. Without that knowledge, we could not
may only be possible within a narrow range of conditions. plan anticipatory actions,10,15,17,18 including the timely de-
Yet, even repetitive and simple movements show pattern celeration of movements in order to successfully grasp ob-
variability at any age, because situations are not identical. jects or prevent bumping into them.10 Relying on feedback
In contrast, patients with a movement disorder often use would not work there. In addition to capturing rules of
stereotypic patterns in a variety of situations. Their attun- pattern change, we also understand the time to contact at
ement to the specifics of a situation seems to be disturbed. the present gap closure rate.10 This is based on lawfully
Adaptability to changing situations requires gathering cru- changing information that is picked up visually. Studies
cial information about the situation in which a task is have shown that even the youngest infants reveal remark-
planned. able abilities once the investigator takes a dynamic ap-
proach to perception.15 Information about the existing
ACTIVE PICKUP OF TASK-SPECIFIC INFORMATION structure in the environment can be directly obtained
Theory based on spatio-temporal transitions that follow physical
laws. Re-constructing the environment from various depth
The adaptation of postures and movements to con- cues is therefore superfluous.8,15
stantly changing situations requires specific and dynamic Learning of motor control involves learning rules of
information about the environment in which we act, our
coordination on a perceptual level rather than memorizing
position relative to environmental features and the relation
specific motor patterns.11,14,18 Discovering these rules of
between various body segments. The focus of task-specific
coordination allows generalization of an acquired skill to a
information is only on those relations and changes of rela-
variety of situations with similar demands.11 Repetition
tions that are essential for the planning and execution of
and experience help patients to discover what needs to be
an action.8 –10,14 General information that has no value for
the intended action is not task-specific.9 monitored, that is, to which information to direct
From a dynamic perspective, perception is informa- attention.11,14
tion-based8 –14 and does not build on sensation. Sensation is Research in early perceptual skills has led to a major
defined as consciousness of the impact of the environment shift in understanding perception. It has become clear, that
on the body. Sensation is imposed on the body and is re- the perceptual system is from the onset very skillful in
ceived through a specific sensory channel. We can attend picking up dynamic and specific information that is impor-
either to an incoming sensation or, alternatively, shift our tant for an action.8,15 Various perceptual competencies are
attention to the available information of a stimulus.8 We present long before they can be applied to motor acts.11
move eyes, head or body to enhance the specific informa- Infants don’t have to learn to convert sense data into per-
tion that we want to obtain. We actively select the infor- ception.8,15 Differentiation of perceptual information is fur-
mation that is of value to us at that moment and we obtain ther refined through active exploration8 and new percep-
such information through all pertinent sensory channels.15 tual skills are continuously learned.
Fig. 2A. Spontaneous behavior before TAMO treatment. The inefficient pattern of bearing weight on the feet and the scarce orienting
information from the legs limit the posture of the whole body in this 6-month-old infant. 2B. Motor pattern with TAMO input. The infant
actively contours his legs to the support surface, and thus, he obtains dynamic information and good postural stability. As a consequence,
he adapts trunk and arm movements.
Pediatric Physical Therapy Applying Dynamic Theory Concepts According to TAMO Therapy 33
Fig. 3A. Spontaneous behavior before TAMO treatment. Weight is born on the trunk because the limbs are pulled away from the support
surface. Thus, rolling is very laborious. 3B. Motor pattern with TAMO input. Therapeutic loading into the weight bearing segments of low
trunk, pelvis and left thigh leads to an active change of weight-bearing posture. Rolling is now well coordinated.
Fig. 4A. Spontaneous behavior before TAMO treatment. During rolling from supine to prone, the infant maintains the same static leg
posture. Head movements shift the center of mass. Intersensory information is not synchronized. 4B. Motor pattern with TAMO input.
With an action-specific loading input by the therapist, the infant optimally adapts his body posture and frees his head for orienting.
patterns for rolling (see Figs. 2B, 3B, and 4B). Not every TAMO handling appear to help patients to feel secure, as
patient has such a high level of competence. But every does drawing attention to an adaptive contact with the
patient has the potential to improve. In TAMO, improve- support surface. Patients will explore new movement op-
ment is measured in increased adaptability, increased bal- tions only when feeling safe. Making the support slightly
ance and increased range of movement excursions. Repe- unstable encourages a broader range of postural adapta-
tition of an activity helps patients to discover which tions. Alternatively, more external support is given as is
information needs to be monitored. The value of such per- natural for an earlier skill level; sufficient support allows
ceptual learning can hardly be overemphasized. adequate adaptations to be learned. This requires consid-
In TAMO, any input is considered a potential source eration of the various stages of skill development based on
of information. Therefore handling input must always pro- working with forces produced by the organism and the
vide meaningful and task-specific information. The thera- environment rather than focusing on the specific configu-
pist slightly accentuates gravitational force vectors that rations of patterns.
naturally load the body. This draws the patient’s attention TAMO handling never modifies a pattern configura-
to the information that is associated with an action. To tion through guidance of movements, correction of move-
increase informational input to body segments that are not ment components or stimulation of muscle groups. Sen-
in contact with a surface, pliable objects, such as pillows or sory stimulation, resistance, mechanical support, traction,
towels may be used to establish contact for bearing weight stretching and other facilitation techniques cannot be re-
dynamically. Therapeutic input is never dominating, but produced by the patient; therefore they are not used in
very gentle and dynamic. The therapist never gives resis- TAMO therapy.
tance but allows self-activation and exploration of actions The changing loading vectors of therapeutic input
that are available to the system at that moment. Changes of cannot be seen by an observer; neither is the patient’s prob-
the direction or intensity of therapeutic loading must be lem solving obvious, except that patients may noticeably
subtle, slow and succinct to allow postural adaptations by quiet down, become attentive and their actions become
the patient. The capacity to perceive information for many more skillful. This may be most striking when treating
movement phases seems to be important for optimal move- hyperactive children. The observed movements often look
ment control and for achieving better perceptual differen- relatively easy. Unless the observer knows the patient’s
tiation. The gradual and slow changes associated with limitations, the full scope of ongoing learning may not be
Pediatric Physical Therapy Applying Dynamic Theory Concepts According to TAMO Therapy 35
Fig. 5A. Spontaneous behavior without treatment. This 11-month-old girl needs to tilt the head to counteract the gravity dominated body
posture. Perception and action are not matched. 5B. Typical motor behavior. This 4-month-old typical infant adapts the posture of the
upper trunk to counteract the age appropriate inactivity of the low trunk. Her adaptations allow a vertical head posture for consistent
information pick-up.
about 3 months, the weight-bearing surface starts to shift front in this situation, but handles from the back of the
to the lower trunk and the head becomes free for inten- trunk. The therapist changes the loading pattern from an
tional spatial orientation. Now, the caudal segments of the anterior-posterior to a cephalocaudal direction. Thus
body learn to orient to the support surface through goal the child is re-directed to seek stability by leaning into
directed movements of the upper body, especially while in the natural support surface contact, which is formed by
the prone position. Selective stabilization against the sup- the thighs and the buttocks at the most skillful level.
port surface guarantees controlled movements in the rest Before that stage is reached, patients are encouraged to
of the body and counteracts destabilizing gravitational lean on the arms or to lean against a back support.
torques. During the course of development, each segment Proper head orientation can also be achieved with an
of the body interacts adaptively and dynamically with the early strategy of pronounced trunk extension. At a very
support surface. The pressure of bearing weight at the sup- early stage, patients are expected to actively adapt the
port surface contact informs about the orientation to the head posture while the therapist provides adequate, dy-
horizontal-sagittal and the vertical planes. Changes of the namic support to the trunk and pelvis. Subsequent goals
distribution of the pressure of bearing weight contribute to are adaptations of the upper thoracic spine, with or
more differentiated perception and establish more differ- without arm support. Coordinated shifting of the weight
entiated movements. Efficient orientation to gravity is of the trunk and pelvis occur later. In each phase of
based on adaptive and dynamic patterns of bearing weight.
treatment, patients are taught to orient cephalo-caudally
In addition to improving spatial perception, treat-
around gravity according to their skill level.
ment also has to address body perception. Information
TAMO handling includes also a purely informational
about one’s own body may be fragmented in connection
touch that does not change the loading distribution. Infor-
with perceptual-motor problems. Contributing to it are
mation about spatial orientation can be enhanced through
postures that never allow dynamic weight bearing on
a very gentle touch that yields when the patient seeks me-
certain body segments; those body segments are conse-
quently stiffly stabilized. On the other hand, postural chanical support. These subtle, gentle forces provide infor-
inactivity and rather passive postures equally limit in- mation about body alignment and spatial orientation with-
formation pick-up, even if the contact with the support out offering physical support.
surface is large. Bearing weight dynamically is used to Newly acquired perceptual-motor skills need to be
explore available movement possibilities in either situa- always implemented into the actions and positions that
tion. Therapeutic handling input needs to consider the the patient usually performs. The new organization
information that is provided. For example, for a child should result in better coordination, but movement pat-
who tends to fall forward in sitting, one would instinc- terns may be unstable in the beginning. It is not uncom-
tively want to block the body from falling further for- mon to see patients alternate between old and new
ward by supporting the body from the front. However, movement strategies. This is an indication that more
support to the chest encourages the child to seek stabil- than one pattern can be used in the same situation. It is
ity and security by leaning forward into that support. important to start treatment with the movement patterns
Consequently, such handling strengthens the movement the patient spontaneously assumes; thus, patients learn
that causes the child to loose balance; also, the child is how to move out of preferred and habitual patterns be-
prevented from finding a better movement strategy. In fore exploring new movement possibilities that better
contrast, TAMO handling does not support from the utilize appropriate external forces.
Pediatric Physical Therapy Applying Dynamic Theory Concepts According to TAMO Therapy 37