TOMT is a task oriented, constraints led, approach underpinned by six processes:
- Identify the developmental tasks that the infant or toddler has not yet mastered at an age appropriate level.
- Identify goals for performance of the developmental tasks within the family environment.
- Identify the factors within the infant-task-environment interaction that constrain/limit or enhance task performance.
- Adapt the task or environment to allow the infant to successfully perform the task.
- Provide repeated opportunities for practicing the task, in a variety of circumstances that allow the infant to explore different options for achieving their goals.
- Increase task demands (the level of difficulty) over time by adapting the task and/or the environment.
How these processes influence movement therapy effectiveness
1 Parent led, family focused goal setting enhances parent engagement
A collaborative process of goal setting helps to identify the developmental tasks that the parents would like to improve.
Task training that clearly addresses parents' goals enhances parent involvement and commitment to home based training. This is important because infants only learn when they have repeated opportunities for practicing new skills.
2 A constraints led approach to task analysis identifies all the factors affecting task performance
Constraints led task analysis looks at all the factors within the task-infant-environment interaction that constrain (limit) or enhance performance.
This knowledge allows the therapist to adapt the task and or environment in a systematic manner to allow the infant to succeed at the task. Success motivates the infant. Repetition and meeting challenges enhances the infant's abilities: strength, flexibility, coordination and use of information to guide actions.
Jake (24 months) refuses to step up or down a 10 cm high step on a path leading from the back door to the garden play area. Instead he calls for someone to come and give him a hand to hold onto.
The problem seems to be related to confidence and balance rather than strength because he is able to walk up and down a short flight of steps holding onto the stair rail.
Assessment included getting Jake to step up and down from a 5 and 10 cm step placed close to a wall so that he could touch the wall for support as he stepped up and down. He happily stepped up with his hand on the wall, but refused to step down unless he held his mom's hand. It was noted that he had difficulty keeping the back foot aligned in a forwards direction when stepping down, and instead twisted it laterally.
3 Use of age appropriate task lists allows the therapist and parents to identify strengths and weaknesses
Often parents are so focused on the things their infant cannot do that they fail to recognize the tasks that their infant is good at. For this reason it is very important for parents identify the things that the infant can do well.
Identifying the tasks that the infant is not able to perform at an age appropriate level helps parents identify goals that are task specific.
Jake's parents were concerned about his balance and tendency to fall frequently. Jake had learned to walk at 18 months, but now at 24 months was very active and often would run rather than walk. The falling did not seem to bother him and he rarely hurt himself.
Using the SfA Toddler Gross Motor Checklist the parents and therapist identified a few locomotor tasks that Jake could not do: stepping up and down a small step independently, walking on uneven and rough ground, stepping over a small obstacle, walking on a raised surface.
4 Task oriented training addresses all aspects of task performance
Motor learning, planning and control are all task specific. Strength training is task specific. Balance control is task specific.
The balance control needed for walking on a narrow raised surface is different from that needed for lifting and carrying heavy bottles.
The LE strength and control needed for sitting down with control differs from that needed for stepping down from a step.
5 Task training can be progressed in a systematic manner
Once the constraints that impact on task performance have been identified, the task demands and environment can be adapted in a systematic manner to challenge different aspects of the task.
When infants first learn to stand with chest high support their balance is precarious and they are in danger of falling.
Standing facing a lower support surface allows the infant to lean forwards and rest on the forearms or even the chest. In this position the infant is fairly stable and can explore different options for shifting weight over the feet and reaching for toys.
6 Task oriented training allows therapist to plan and implement intervention in a systematic manner
A task oriented, constraints led approach to intervention allows therapists to select and progress training activities in a systematic manner, with confidence that they are addressing all important aspects of the infant's development.
Intervention planning should be a principled activity guided by sound clinical reasoning based on the best available information on motor control and motor learning.
Josh (3.5 years) is an active little fellow who moves about the house at speed, but his mother is concerned about his frequent falls. He has also recently climbed up onto a dining room chair, jumped down and knocked his forehead on the floor.
A review of all the locomotor tasks Josh encounters at home and at school, identified the particular tasks that lead to falls: stepping up and down from a small curb, stepping over obstacles in his path, jumping down from a low step, making sudden stops and turns.
7 Task oriented training allows progress to be documented in a meaningful way.
Goal attainment scoring allows the progress towards achieving identified goals to be documented.
Goals should be described in terms of specific tasks that the infant needs to master. Steps towards achieving the goals are identified and progress is monitored on a regular basis.
Final goal: Josh will be able to climb up onto a dining room chair, stand up and then jump down from a dining room chair, and land safely putting his hands out to break his landing.
Intermediate goals:
- Josh is able to step up onto a low (10 cm high) box and jump down, bending his knees and reaching forwards to control his landing.
- Josh is able to climb up onto a 20 cm high box, stand up and jump down,with his hands to control the landing.
- Josh is able to climb up onto the sofa (30 cm high) and jump down onto a 15 cm cot mattress.
- Josh is able to climb up onto a dining room chair, stand up and jump down onto a 15 cm thick cot mattress.