The TOMT assessment of standing follows the stages in standing  with external support seen in typically developing infants, with attention to five important underlying abilities that emerge over time with experience:

• adapting the amount of tension (stiffness) in the lower limb muscles in response to changing alignment of the body segments and task demands;
• realigning the relative position of the trunk and body segments to maintain the center of mass (COM) over the base of support (BOS) with changing task demands;
• use of exploratory postural sway to provide information about the position of the body in space. 
• ability to extend the knees without locking them into hyperextension 
• a desire to stand - and attention to maintaining a standing position

Standing with caregiver support 
Support the infant around the chest in the upright position.

Observe

• Does the infant extend the LLs and take weight on the feet? 
• Are the hips in extension, or are they in flexion?
• Does the infant engage in small flexion and extension movements of the knees or are the knees held stiffly in extension?
•    

Does the infant flex the hips and knees, or flex the hips with the knees extended (sitting on air) when supported upright? 

Standing with waist-high external support

Let the infant stand facing a waist high external support. The infant may choose  to take weight on the chest, on the forearms or on the hands with extended elbows. 

In this position the BOS is larger and the infant is relatively stable and the child will usually start to reach for toys, start to explore LL movements and shifting weight in an AP and lateral direction. 

Postural sway in a lateral and A-P direction can be observed. 

Observe 

Trunk and upper limb position and weight bearing 
Does the infant choose to take weight on the chest, on the forearms or on the hands with extended elbows?

LL alignment, hip position and knee extension
►  Do the infant's feet remain flat on the support surface? What is the alignment of the feet? 

If the infant is supporting themselves on the chest, they may start to explore extending the hips and lifting the feet up off the floor. 

►  Are the infant's feet positioned hip width apart or in some abduction?  

►  Are the knees fully extended or flexed? 

►  Does the infant play with small flexion and extension movements of the knees as they explores different options for supporting the body weight on the LLs?

Reaching and weight transference 
►  Does the infant lift one hand to reach for a toy? 

► Does the infant make effective adjustments in weight bearing over the LLs when they each for a toy? 

Standing with chest-high support 
Let the infant stand facing a chest-high support surface.  With chest-high support a typically developing infant, after some practice, will stand with the the hips in extension and use the hands for balance rather than support.  

Observe

Use of trunk and ULs for support 
►  Can the infant stand with light hand support or does the infant lean the chest against the support surface or take weight on the forearms? 

Hip position and LL alignment
►  Are the feet aligned more or less pelvis width apart, with maybe a few degrees of abduction. Or are the feet placed wide apart with > 10⁰ of abduction

►  Are the hips extended or in slight flexion?   

►  Do the feet face forwards or are they laterally rotated? 
►  Are the knees flexed a few degrees or fixed in hyperextension? 

Reaching in all directions 
Any reaching action with one hand requires an adjustment in the alignment of the COM over the BOS which is formed by the LLs and the contralateral hand. 

Remember that effective balance when lifting one hand is accomplished by shifting the weight onto the ipsilateral LL and contralateral UL. 

Reaching in all directions 
Encourage the infant to reach to the side, up and backwards. 

►  Can the infant reach up and backwards?  
►  Does the infant realign the trunk and limbs to maintain balance? 

►  Can the infant reach sideways to a toy that is just out of arm's reach? 

• Does the infant shift the COM laterally and adduct the ipsitateral hip when reaching for a toy that is out of easy reach.  
• Does the infant take a small step sideways to get closer to a toy that is placed beyond arm's reach 

►  Does the infant take small steps the realign the COM over the BOS as he reaches for toys in all directions? 

Reaching down to pick up a toy from the floor 

►  Can the infant reach down to retrieve a toy from the floor. 

Do thhe achieve this task by flexing the knees, or do they keeps the knees straight and tip the trunk forwards. 

Sitting down with control
►  Does the infant sit down by flexing the hips and knees? 

►  Or does she fall back into sitting with the knees in extension? 

Stepping and cruising 

Stepping sideways to reach out of reach toys
►  Has the infant started to take small steps sideways to reach for out of reach toys?  

Cruising - repeated steps sideways 
►  Has the infant started to take repeated, rhythmical steps sideways to move sideways?  

Cruising involves a swing and a stance phase for each LL, as well as lateral shift of the COM over the stance LL, with the stance hip moving from abduction to adduction. 

Walking forwards pushing a chair
►  Can the infant step forwards pushing a chair or step?

 ►  Does the infant respond to forwards movement of the support surface by taking alternate steps forwards? 

Pull-to-standing from sitting or kneeling 
►  Is the infant able to pull themselves up into standing transitioning through half kneeling? 

►  Or does the infant themselves up using a bilateral hip and knee extension pattern? 

Standing without support - letting go and balancing 
►  Has the infant started to let go and stand without hand support?

Balancing in unsupported standing usually starts to elicit ankle balance responses.

Does the infant let go and move across a gap? 

Bibliography
Atun-Einy O, Berger SE, Scher A. Pulling to stand: common trajectories and individual differences in development. Dev Psychobiol. 2012 Mar;54(2):187-98.

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Activities for training standing