Author: admin

Courses: Understanding Pain

After completion of this course, participants will be able to asses, evaluate, develop, implement, progress, regress and conclude a safe, evidence-based approach to allow for specific functional outcomes regardless of therapy background or treatment setting.

We are currently seeking input from rehabilitation and sports performance professionals about what answers they would like this course to answer. If you have a question regarding this subject, please complete the form below. Thank you for your involvement.

Career Outcomes – Quick Mentor Series

A successful career in the field of physical therapy involves organizing around 3 major components.  A mentoring relationship helps to clarify the desired outcomes in the components and makes a clear assessment of the mentees’ current performance levels.  The three career components are:

  1. Orientation
  2. Clinical Decision Making
  3. Technical Skills

Each component works to support the other two, and in turn is supported by the outcomes made.  Orientation refers to not only the clarification of the values that are the foundation of ones practice but also the structures chosen to give expression to the values. Ones orientation towards the reason, the purpose for being involved in the field will influence the technical skills required to attain the end results.

Clinical decision making is an outcome of the structures chosen in the orientation and is directly impacted by the tensions that the structure produces.  It also informs the technical skills that will be utilized as the higher degrees of complexity of clinical decisions require specific techniques that are reproducible and reliable in order to clearly identify the impact made by action.

And finally there is the craft, the technical skill and expertise that supports the actions that are made from the clinical decision making process and ultimately are a reflection of the orientation of the clinician regarding values, aspirations, and use of structures that are relational or transnational.

  • Adaptive Equipment
  • Admission and discharge planning
  • Advising
  • APTA Core Values
  • Balance Testing
  • Balance
  • Bed Mobility
  • Body Mechanics
  • Building Rapport
  • Cardio Pulmonary
  • Case management
  • Change Readiness
  • Chart Reviews
  • Choosing the Measurements
  • Clinical Decision Making Elements
  • Clinical Decision Making
  • Clinicial Impact
  • Cognition Tests
  • Collaboration and coordination with agencies
  • Collaboration
  • Collecting Data
  • Communicating to different audiences
  • Communication across settings
  • Communication
  • Conflict Resolution
  • Congruence
  • Consultation
  • Consultative Practice
  • Coordinating Care
  • Core Values
  • Cost Resources
  • Cranial Nerve Tests
  • Credibility
  • Cultural Competence
  • Data collection
  • Data Overload – Shortcut
  • Data Overload
  • Demographic Impact
  • Developing your Network
  • Disability
  • Discharge Planning
  • Documentation of Care
  • Documentation
  • Drawing Conclusions
  • EBP Outcomes
  • EBP
  • Educating like a Pro
  • Environmental Assessments
  • Evaluation
  • Examination
  • Family Conflict
  • Fundamentals of Communication
  • Fundamentals of Practice Management
  • Fundamentals of Professionalism
  • Gait and AD
  • Gait Assessment
  • Gait on Uneven Surfaces
  • Health Promotion
  • HIPAA
  • Identifying Core Values
  • Inflammation – Tissue Healing Phases
  • Informatics
  • Integument
  • Interdisciplinary teamwork
  • Interpersonal Communications
  • Intervention – Adaptive Equipment
  • Intervention – Airway
  • Intervention – E Stim
  • Intervention – Functional Training ADL
  • Intervention – Functional Work
  • Intervention – Manual Therapy
  • Intervention – Physical Modality
  • Intervention Integument
  • Interventions General
  • Knowing when you know – Vitals
  • Levels of Evidence
  • Making Referrals
  • Marketing
  • Mentoring
  • Motor Function Tests
  • MusculoSkeletal Exam
  • Negotiations
  • Neuro Development Exam
  • Non verbal communication
  • Orthotic Tests
  • Outcome Measures
  • Pain
  • Patient Client Education
  • Picturing
  • POC Design
  • POC Development
  • Posture
  • Precautions
  • Prevention
  • Productivity
  • Professional Collaboration
  • Professionalism
  • Prognosis
  • Progression of POC
  • Prosthetic Tests
  • Providing Evidence
  • Pulling it all together
  • Quality Improvement
  • Questions
  • Reflex Testing
  • Reimbursement
  • Risk Management
  • Safety First
  • Screening
  • Self Care Assessment
  • Sensory Testing
  • Share a good thing
  • Strategic Conflict Resolution
  • Structural Thinking and Databases
  • Supervising the PTA
  • Systems Review
  • The flavor
  • The Negative Space
  • Ther Ex Aerobic Conditioning
  • Ther Ex Balance
  • Ther Ex Body Mechanics Postural Stabilization
  • Ther Ex Flexibility
  • Ther Ex Gait Training
  • Ther Ex Kegel
  • Ther Ex NDT
  • Ther Ex Relaxation
  • Ther Ex Strength
  • Ther Ex Ventillatory
  • Transfers
  • Wheelchair
  • Work Ergonomics
  • Writing Case Studies – Professional

If you have a specific question about any of the topics above please submit your questions using the form below.  Thank you for your involvement.

Courses: Fall Prevention

After completion of this course, participants will be able to asses, evaluate, develop, implement, progress, regress and conclude a safe, evidence-based approach to allow for specific functional outcomes regardless of therapy background or treatment setting.

We are currently seeking input from rehabilitation and sports performance professionals about what answers they would like this course to answer. If you have a question regarding this subject, please complete the form below. Thank you for your involvement.

Experimenting with the Berg – 13. Component 12

Submitted by: Jeremy Nelson PT

12.0 Place Alternate foot on Step or Stool While Standing Unsupported

This component examines the capacity of the patient to perform a weight shift to unload the extremity that is going to perform the step up motion. The goal of the component is to be “able to stand independently and safely and complete 8 steps in 20 seconds”. The time part of the test provides an insight into the overall coordination power that exists in the neuromuscular system. The first task is to perform the weight shift and maintain center of gravity over the base support of the foot into a single limb pattern. The more difficult task comes next, supporting of the stance limb of the stepping up of the contralateral side.

As the lower extremity flexes at the hip and knee to place the foot on the stool, the posterior moment must be countered by the stance limb with an anterior moment. The stance hip must be strong enough to support the COG and BOS relationship in the single limb position as well a counter the posterior moment.
If the performer “needs assistance to keep from falling/unable to try” then presumably the first task was not completed. Without the initial weight shift the stepping lower extremity is unable to be unweighted to perform the motion. This is likely from inadequate control of COG to perform the weight shift or an inadequate BOS in terms of poor foot posture. Reviewing the asymmetrical stance critical tasks into the single limb critical tasks will provide the desired outcomes to measure current reality against.

Again, similar to the other Berg components time is an element to investigate and record speed as function of strength, coordination and power. In order for the extremity to successfully step up there needs to be adequate time for that to happen. The time is developed through the shifting of the body weight to the extremity that is going to be in a close kinetic chain into a single limb position.
As is described in the Component 14 discussion, the single limb position has been involved in many of the movements being examined at the end of the test. With improved single limb support, the control of the step is developed. The strength and control of the extensors and abductor’s are being examined as if there is an inadequacy in either one there will not be enough time for the patient to step up without assistance.

When the performer is “able to complete > 2 steps needs minimal assist” what type of and what degree the assistance is needed is important to identify. When using the upper extremities to assist in stabilizing the COG over the BOS to complete the weight shift points to inadequate gluteal strength or posture of the hip and knee. Assistance required to step up maybe related to the poor knee mobility.

When the performer is “able to complete 4 steps without aid with supervision” and “able to stand independently and complete 8 steps in > 20 seconds” both indicate that the critical tasks are present and the body is able to produce. The difference is a matter of speed and coordination. As the speed increases the size of the weight shift begins to narrow. The larger weight shifts in the lower scores are replaced with small shifts. However this is not to indicate that the forces that the muscles produce to counter are less important. In fact the opposite is true. As the hip strength and power increases the COG is suspended over the BOS for shorter periods of time and the return to the start position. Better control is developed and the performer is able to respond to the demands of life safer and with more confidence.

Experimenting with the Berg – 14. Component 13

Submitted by: Jeremy Nelson PT

13.0 Standing Unsupported One  Foot in Front

The goal of this component is to be “able to place foot tandem independently and hold 30 seconds test hip abductor control as now in relative adduction”. Although not typically part of the function of life (unless your occupation is a tight rope walker) component 13 does provide useful information to assist in developing the overall plan of care. This component is evaluating the capacity of the performer to weight shift, establish new bases of support and maintain the COG in relation to the new BOS. First task is to establish an asymmetrical base of support by stepping forward. In maintaining foot position 1 foot for the other so again was looking at weight shifting in the capacity to control that weight shift with the close kinetic chain lower extremity in addition once the asymmetrical base support is established were examining control the center of gravity over narrow base of support along and diagonal pattern

As the performer demonstrates “Loses balance while stepping or standing” there exists profound inability to control static balance. If the loss of balance comes when stepping then the weight shift did not happen and gravity won the day before the performer was able to establish a single limb BOS. As discussed in the previous articles, any time the performer demonstrates such a low score, the approach would be to step down to the lower level positions and critical tasks. With a review of these supportive tasks, the areas of inadequacies can be improved towards the desired level of the critical task. Having completed the lower level task, the performer will be on a firm foundation for advancement.

Even if the performer “needs help to step but can hold 15 seconds” an examination of the supportive critical tasks are in order. As organized in the hierarchy of movement, the asymmetrical and single limb positions would be supportive to this more complicated task. An inability to weight shift to single limb to establish a new BOS could be present for a number of reasons. What at first looks like a separate test are really the prior critical tasks revisited.

Similar to component 12, time is an element in the test as well as understanding what is required to accomplish the task. It takes time to position the advancing lower extremity into the position that is desired. The scores imply that time for the step to occur is adequate or not. For example when the performer is “able to take small step independently and hold 30 seconds” the weight shift was not likely adequate and the step is a quick step as the brain rapidly attempts to reestablish a BOS before a loss of balance occurs. The time is increased by the strength and power of the stance hip. When the performer has been “able to place foot ahead independently and hold 30 seconds “ an adequate weight shift to during the single limb position has occurred resulting in the establishment of a new BOS, and a capacity to demonstrate to maintain control of COG over BOS.

Experimenting with the Berg – 12. Component 11

Submitted by: Jeremy Nelson PT

11.0 Turn 360°.

Turning around is a difficult task to complete as it requires multiple bases of support and control of the COG to produce weight shifts in different directions. The goal of this component is to be “able to turn 360 degrees safely in 4 seconds or less”. This component includes weight shifts to establish a new base of support while maintaining the center of gravity over that new base of support and also unloading and extremity order to move that extremity. A s discussed in the Component 9 – Picking up from the floor, the Berg is not sequenced in the way that reflects increasing difficulty. As this motions includes the tasks of attaining, maintaining and controlling the COG over the single limb BOS, it would most likely be near the difficulty scale. Ideally the capacity to stand on the single limb, measured in the last component 14 would precede the turning test.

For the practicing clinician its beneficial to understand the critical tasks in each component and how they relate to other functional activities. Included in the turning is the task of stepping posteriorly to establish a new BOS and then accepting the weight shift in a posterior lateral direction. No easy task for the performer with asymmetrical strength or a hypo active inner ear.
Similar to the turning and looking over the shoulder test, the vestibular system and its contribution to control rotations in space is included. During the closing of the eyes test in symmetrical stance examined in component 5, the dependency on the vestibular and sensory system was identified. As a result the rehab professional with an abundance of caution would want to review the test result for that component before testing this component. Although the eyes remain open, the rotational component of the test could provoke a loss of balance.

When the performer “needs assistance while turning” further inquiry is helpful to determine why the assistance is required. Are the signs and symptoms of vertigo present? When does the loss of balance requiring assistance occur? To what degree is the assistance required? All questions that will help to identity the entry point into the change effort. Depending on what critical task requires the assistance, this would be the place to return to. In other words if standing in symmetrical stances requires help, then go to the critical tasks for this position and begin to explore which requires change. If the beginning goes well, and further weight shifts are impaired, go to those critical tasks for further evaluation. When the performer “needs close supervision or verbal cuing” the critical task identified as inadequate will provide the appropriate verbal cuing.

As the performer demonstrates to be “able to turn 360 degrees safely but slowly” the rehab professional will comment on the reason for the deliberate nature of the turn. Often this is due to lack of power to control the weight shifts and provide the emphasis for the quick deceleration of a weight shift and then rapid acceleration of the weight shift to the other lower extremity.

Symmetry between the sides as a goal is examined. If the performer is “able to turn 360 degrees safely one side only 4 seconds or less”, then the asymmetry is investigated. Single limb testing on each extremity will demonstrate the capacity to accept the weight shift. It may also be cause for examination of the vestibular system even if vertigo is not obvious. With a balanced system capable of performing the full turn in the time desired, the performer is well positioned to be involved in their life as they desire.

Experimenting with Berg – 15. Component 14

Submitted by: Jeremy Nelson PT

14.0 Standing On One Leg

This final component of the Berg is not its most difficult as noted earlier. In regards to the hierarchy of critical tasks, this would be around 9 or 10 if the Berg was organized based on difficulty and complexity. The single limb pattern exists in other tests, albeit for shorter periods of time than will be tested in this component. What makes the scoring on this component worthy of being the last of tests is the duration of time each score. The goal requires the performer to be “able to lift leg independently and hold > 10 seconds”. To successfully complete the goal a number of critical tasks are required. The test examines first the weight shifting found in the asymmetrical stance critical tasks and progresses into the control of the center of gravity over a small base of support. On display are the extensors and hip abductors close kinetic chain performance.

What typically undermines the capacity of the performer to attain the test position as in “unable to try or needs assist to prevent fall” is the incomplete capacity at the level of the asymmetrical stance. At this level the weight shifting is inadequate. The critical task in asymmetrical stance as during ambulation from initial contact to midstance is to complete the weight shift on a diagonal. Performers that lose their balance during this position typically perform a weight shift anterior to posterior. In an asymmetrical BOS, this will bring the COG anterior of the BOS and result in the patient losing their balance to the trailing limb side. Once the performer is able to learn the weight shift from trailing limb to the forward limb on the diagonal they are well positioned to attempt the single limb position.

To be able to lift the leg off the ground during the “tries to lift leg unable to hold 3 seconds but remains standing independently” the weight shift has occurred, however the stance lower extremity is unable to maintain the COG over the small BOS. Typically the cause is at the hip, which demonstrates instability in various planes. If the mobility of the hip is adequate to attain the knee at extension and hip at neutral, then the next task is to coordinate the hip to position the COG over the BOS. Most often the performer fails to pass 3 seconds because they have returned to the start position by falling towards midline. In other words the initial weight shift was only to the medial edge of the stance LE. The lesson here is to promote greater weight shifting to the stance LE. Focusing on enhancing the power of the hip abductors and extenders to perform in a closed kinetic chain will increase the duration of the single limb stance.

As the performer is “able to lift leg independently and hold ≥ 3 seconds” and up to “able to lift leg independently and hold 5-10 seconds” conclusions regarding the safety on different surfaces during ambulation can be made. As uneven surfaces take a longer time for the step to take place and thus require greater time in the single limb position, the performer can be considered safer as the capacity for single limb stability improves. As was described in the picking off of the floor, there can be progressions within the scoring matrix, with the changes of the BOS surface. Moving from a firm tile surface to a more compliant carpet surface provides increasing challenges regarding the establishment of the BOS and the control of the COG over the BOS. As the challenges increase and the performer progresses through this component they will find that they are better able to be involved in life as they desire.

Experimenting with Berg – 11. Component 10

Submitted by: Jeremy Nelson PT

10.0 Turning Look Behind Over Left and Right Shoulders While Standing.

This component is the first times that the test is examining the ability of the core musculature to control the center of gravity in a rotational pattern. Rotation is critical to functional movement. This test specifically looks at rotation in a symmetrical stance around a midsagittal axis. Function happens in three dimensions and rotation is a motion used when performing diagonal movements. Without diagonal movements necessary weight shifts would be difficult to produce. The goal of this component is “looks behind from both sides and weight shifts well”.

Starting from the end, the weight shift is the first element of the structure to consider. For only after the weight shift is successful can the performer complete the looking over the shoulder. Controlling the rotation motion so that the COG can move towards the rotation foot and the hip extensors and hip abductor’s are able to control the weight shift to the ipsilateral extremity is the domain of the hip joint and requires good core stability.

Not only is the motor system on display but also is the vestibular system and its ability to control balance while the head is rotating. In order to successfully perform the looking over the shoulder their needs to be an adequate weight shift towards that side of that the patient is looking towards. Adequate vestibular input is a key to this weight shift and maintaining the COG over the BOS during the rotation.

As in many of the berg tests it is advisable to comment on what is seen in terms of strategy. The movement strategies that are being employed are important to identify as they will provide a place to start with the change effort. Recognizing if the rotation is occurring at the pelvis, trunk or neck and to what degree these body segments are contributing will explain the causes implied in the scores. When there is motion around the hip joint and control through the hip extensors and hip abductor’s then the body is good position to turn around the axis. When rotation is occurring at the lumbar spine this is due to inadequate mobility at the hip or thoracic spine or both.

When the performer “needs assist to keep from losing balance or falling” there is more to explore in terms of why the performer is falling. Is there a sense of vertigo present that would provide cause for an examination of the vestibular system? Is weight shifting adequate in the frontal plane? If so how does it different from the addition of rotation? All of these questions will be useful in organizing the change effort to focus on the causative factors. Moving to the “needs supervision when turning” score is a sign of progress; however this score still indicates that body segment contribution is not adequate. Something is limiting the crucial weight shift to the ipsilateral lower extremity.

As the performer is able to “turn sideways only but maintains balance” the weight shift that was absent before is present. Only if the weight shift occurred would balance be maintained with turn sideways. In addition the contribution of the hip would be deemed adequate in this position. Without adequate hip mobility, reaching the sideways position would be likely impossible. Adequate weight shift to the ipsilateral side will promote the necessary internal rotation required as well as the external rotation of the contra lateral hip. Without the weight shift the rotation promotes a posterior lateral shift, causing the performer to lean back.

In deed the next score of “looks behind one side only other side shows less weight shift” could indicate a lack of ROM at the hip joints. Range of motion will also be required of the thoracic spine and cervical spine to complete the looking over the shoulder maneuver. By limiting the hip rotation by placing the performer in the seated position, and continuing the motion, the clinician can identify the contribution of the thoracic spine to the rotation. Lumbar spine rotation occurs if the performer does not first attain the upright posture with a slight anterior pelvis tilt. A posterior rotation of the pelvis will cause the lumbar spine to flex, providing emphasis for lumbar spine rotation. This can give the appearance of limited thoracic spine mobility. Finally cervical spine mobility is assessed as the thorax is restricted.

Experimenting with the Berg – 11. Component 9

Submitted by: Jeremy Nelson PT

9.0 Pick Up Object From Floor From a Standing Position

Although 9th on the list of tests in the Berg, when examining this component for complexity it is near the top of difficulty. The goal of this component is to be “able to pick up slipper safely and easily”. How the performer completes this goal can be divided into a number of possible strategies; one that is a symmetrical stance involving a full hip hinge or squat, or an asymmetrical stance involving a modified split squat and finally as a single limb golfers lift. As a result, this component allows us to not only learn something about the current control the center of gravity in a changing base of support but also lets us know the preference for movement.

Strategies that the performer demonstrates in order to accomplish the task identifies which BOS they are most comfortable. The split squat pattern in which the person squats down to pick up the object from near the feet provides information about the asymmetrical BOS. The golfers lift in which the performer goes into a single limb to pick up the object implies a higher degree of neuromuscular development. This will be useful in organizing the change effort to come as well as knowing where on the hierarchies of critical tasks to begin and progress.

When the performer is “unable to try/needs assist to keep from losing balance or falling” there exists a profound inadequate control of the COG. This shouldn’t be a surprise at this point in the testing as the prior test components would have provided evidence the level of complexity demonstrated in this component would be unattainable. As discussed in the prior articles, this score indicates that there is work to be done in the prior supporting levels. Basic critical tasks are absent and the body segments utilized to complete these critical tasks are inadequate in more than one way.

When the performer is “Unable to pick up and needs supervision while trying” it is worth noting which base of support strategy was employed. A change effort to improve the performance in this component would most likely start in the base of support that is presented. Symmetrical base of support using the hip hinge would return to the prior functional reach critical tasks. An asymmetrical base of support could include the split squat as an entry point. And if the performer presents the golfers lift, the stance phase of ambulation would be a good entry point to consider. A problem solving approach, without considering how something is moving and seeing this simply as lack of lower extremity strength will be unlikely to succeed. There is simply to many data points that are related to consider one solution as adequate.

As the performer demonstrates “unable to pick up but reaches 2-5 cm(1-2 inches) from slipper and keeps balance independently” an adequate control of the COG over the preferred BOS can be implied. At least to the point of near the ground. The question here is whether the inability to reach the ground is due to mobility, inadequate flexibility of the body segment, or inadequate stability to attain the control required reaching the ground and return. The human brain is very good at knowing its limits and not getting caught into a position it can’t get out of. What at first looks like inadequate flexibility of tissue to attain a position could also be neurological based muscle guarding as the edges of coordinated movement are reached.

To investigate the questions, the first place to start is to return to the critical tasks of each base of support and investigate what level of flexibility and mobility exist. The seated hip hinge with reaching to the ground demonstrates adequate flexibility if all body segments perform as expected. As the base of support narrows and the complexity of the movement increases, the investigation turns to dynamic stability. The golfers lift is a complex movement that more likely indicates control of the COG to complete the task then flexibility. Further control would be demonstrated by “able to pick up slipper but needs supervision”.

By including the BOS as a data point when observing this component, further progressions or regressions can be organized. As the performer attains the goal in a symmetrical stance, move to the asymmetrical stance to complete the picking up of the object. Having attained the goal in the asymmetrical BOS, the single limb BOS is available. In this way the patient is provided a wide range of demands to learn from, resulting is greater preparation for the demands of the real world.

Experimenting with the Berg – 10. Component 8

8.0 Reaching Forward with Outstretched Arm Standing
The reaching component of the Berg is also found in its own test, the Functional Reach. It provides information about the balance. This component tests the strength of the extensors and eccentric motion of the hips in order to control the forward bending of the body at the hip joint. As the hip joint flexes and the center of gravity moves towards the anterior portion of the base support there is also a shift backwards by the core in order to maintain the base support center of gravity. If the body segments can complete these critical tasks, then the relationship of the COG and BOS is supported and the performer stays upright. As the arms reach out further, flexion at the hip occurs.Each score in the component provides valuable information regarding the state of the body segments and data to organize a successful change effort.

When the performer “loses balance while trying/requires external support” the body segments are not adequate to produce the critical task of the maintaining the COG over the BOS. This is similar to the earlier components that examined the capacity of the neuromuscular system to produce static stability. Without adequate control of static balance to begin a forward motion the performer will lose balance or attempt only with upper extremity support. Going further in the test would be likely counterproductive and possibly dangerous. Returning the upright posture of the lower extremities into extension and the pelvis into neutral maybe enough to regain the static control desired. Clearly there is work to be done at the supportive critical tasks and a regression to the basics is the best move forward.

When the performer “reaches forward but needs supervision” the body has developed through adequate posture and strength to maintain the static balance and to begin tentatively to extend the upper extremity away from the COG. As the arm extends this shifts the COM anteriorly. The body reacts by producing an extension moment on the lumbar spine as a counter force. Typically this looks like lumbar spine flexion as the performer reaches out to attempting to maintain the COG over the BOS without moving. This tug of war provides stability however ultimately limits the capacity of the body segments to support dynamic control of the COG within the BOS.

When the performer “can reach forward 5 cm (2 inches)” the observer would recognize the shift of the COG to edge of BOS by transferring body weight on to the metatarsal heads. As the reach proceeds the BOS begins to change from the full foot to the rise of the heels on to the metatarsal heads. Predictably the performer will be straining as strong gastrocsoleus is required as a counter force. The problem solving approach would be to seek to enhance the lower extremity strength to counter the forward motion, or to improve the posterior chain to again pull the body back. Instead the loss of balance indicates that the COG has left the BOS, most likely moving anterior of the BOS.

However no matter how strong the lower extremities are, completing the “can reach forward 12 cm (5 inches)” and “can reach forward confidently 25 cm (10 inches)” will not be attainable. What is required is a critical task to maintain the COG over BOS. The key is the standing hip hinge. Ironically in order to reach more forward, must be better at maintaining the COG above the BOS through the use of posterior weight shift. The hip hinge has been present before, however in the seated position and as a critical task of the sit to stand to sit components. In the standing symmetrical position utilized for this test, different body segments are contributing to the movement in different ways. Knee extension is required to perform this test and as such requires adequate biceps femoris length to attain the knee extension position. This is not enough to complete the test however, as the biceps femoris must also be flexible and strong enough to assist in controlling the anterior pelvic tilt that is part of the hip hinge movement.

Without adequate length and/or strength the biceps femoris through its origin on the ischial tuberosities will limit the anterior pelvic rotation and initiate a posterior pelvic tilt. As this occurs the lumbar spine will be forced from the extended position into relative flexion, resulting in loss of control of the posterior weight shift maintaining the COG within the BOS. The posterior weight shift to assist the forward reach will be impossible to complete, resulting in a loss of balance.

Within the context of hierarchies of critical tasks it is best to step down to the level of the squat progressions to practice the hip hinge. Using the standing hip hinge to initiate stand to sit, variations on theme can be used to enhance biceps femoris length and eccentric control. Control of the COG with this new available mobility can be practiced with the anterior weight shift in the seated position. From there the BOS is changed to symmetrical stance and the hip hinge with the posterior weight shift introduced.