Experimenting with the Berg- 2. Choices of Structures

Submitted by: Jeremy Nelson PT

The key to building tangible results over time is described by Robert Fritz as first establishing structural tension. He describes this tension as not stress or anxiety but instead the state of two complementary and different points in relation to each other. Generally it is the relationship between the desired end result, the outcome that is wanted, and the current reality as it is defined in relation to the outcome. By first establishing the relationship a dynamic is generated that supports the choices and actions on a strategic basis. Other structures are available, such as a problem solving structure in which the intensity of the problem drives the actions. Which structure the clinician chooses to use will influence the interventions selected as well as the impact on functional outcomes.

Starting with the first element, a desired end result is required. As mentioned before, each component part of the Berg has within it sub elements. These observational descriptions for that movement are organized from unable (score of 0) to fully capable (score of 4) with each score providing a defined task to complete. Used primarily as a scoring matrix, this could also be a framework for goals of towards progression of the patient through that component. So an example would be 1.2 able to stand using hands after several tries the goal would be 1.3 able to stand independently using hands and so the treatment plan would be then to move towards that goal.

The cause of poor function is absent in the testing tool, and is the domain of the clinician to evaluate the contributing body segments that are required to support the center of gravity relationship in the test component. Which interventions, and the success of progressing through a component and then into higher levels of complexity depends on the overall structure of the plan of care.

Problem solving structure will seek to eliminate the restriction that is stopping the movement to the next level. Interventions applied will be utilizing therapeutic exercises, may be soft tissue mobilization, maybe neuromuscular reeducation, to get rid of the problem. As the intensity of the problem decreases, for example pain is reduced; the motivation for further action also decreases. Now the patient can stand up independently. However the cause of the problem is left unaddressed and the physical capacity to support the transitional movement has not changed, and as a result the patient is prone to recidivism.

A plan of care that is composed using the establishment of structural tension as a strategy will promote specific exercises that are related to each individual component and subcomponents as well as change over longer periods of time. The individual exercises focused on the critical tasks that are found within each component. So again an example borrow 1.2 able to stand hand-in-hand using hands actual tries and then 1.3 able to stand independently using hands. Employing the sitting hip hinge exercise in which the patient goes from hands-on knees slightly hands down inside of the tibia’s towards the medially malleoli supports the critical task at hand.

Enhancing the anterior weight shift is the goal, to move the COG over the BOS. Using this specific exercise mobility of the hip joint is enhanced. And it is enhanced in a closed chain, providing needed learning for the surrounding musculature to improve timing. The adequate hip hinge also supports the stability of the core in order to control of the change of the center of gravity within the base of support.

It could go another way. That the person who is learning the motion has adequate hip hinge ability an adequate core strength however the base of support that they’re establishing is too far forward from their ability to transfer their center of gravity over their base support so this may include working on ankle and knee mobility in order to increase flexion of the knee increased dorsi flexion of the ankle. This brings the base of support closer to the center of gravity thus facilitating their ability to successfully transfer the center of gravity on top of the base support. In this example the person still needs to utilize their hands in order to develop the force are developed to control however there now able to do that without concern of falling.

With a composed plan of care, the related motions and component segments are included in the in the clinical decision making process. From here the change effort can proceed. Using a problem solving structure will be inadequate, resulting in a limited improvement in function primarily focused on putting out the fire, not designing and constructing a new building. Over the series of articles we will examine each component of the Berg as an experiment in application of different structures as part of the clinical decision making process.

Experimenting with the Berg – 1. Introduction

Submitted by: Jeremy Nelson PT

The purpose of the following series of articles is to provide the interested professional specializing in the study and improvement of human motion, the opportunity to examine each component part of the Berg balance scale. The Berg Balance test, as well as being a widely measure of a persons’ capacity to avoid falling, it also provides a framework for an interesting experiment in plan of care and treatment planning. As a structure for treatment planning as within each component part the sub-component parts in terms of the descriptions of the observations, it also provide a goal for progression of the patient through their treatment plan. Absent in the testing is an explanation of why the persons is having difficulty at one level. This is the role of the clinicians, to observe, examine, evaluate and understand cause and affect relationships. Now the clinician can develop a change effort through treatment planning. How the Berg is used will be a critical factor in how the change effort succeeds.

Often the Berg is used clinically as form of snap shot in time. Like a photo it describes something that happened at a particular moment. Over the course of a plan of care, the test is used at regular intervals to document change over time. The implication is that if progress is being made, it must be the result of the interventions performed. Often the plan of care is not related to the Berg test other than as the snapshot previously described. Where then is the evidence that the interventions are in fact causative? If good things are happening, it would be nice to be explicit about the relationship between the functional change and the interventions rather than remaining implied.

However another approach would be generate the plan of care as a derivative of the functional outcome tools being used. In this way, as change is documented there is a direct relationship between the change observed and the actions taken to cause that change. It would also be valuable to know if the interventions are not effective, resulting in a measurement indicating a lack of change. For the clinician this valuable information and provides real data for the clinical decision making processes that are the hallmark of skilled care.

In order for the Berg components to act as jumping off points into treatment planning, it is helpful to examine each component for the bio mechanical tasks that support functional movement. Each of the Berg balance components is a well-diversified evidence-based functional outcome tool in of itself. As a whole it has acceptable reliability and validity as an assessment tool. It measures what it says it measures, consistently between uses. As a starting point for a change effort it provides a firm foot hold. In the following articles we will explore in what way structures influence which way the treatment goes from there. The approaches suggested are simply that, suggestions and are not recommendations. Each is up to each clinician to choose the interventions that are correct for the patient at that time. Only through the skilled capacities of a clinician can real change be developed to restore and enhance a patients capacity to be involved in a life as they desire.

Click on the link below to download a copy of the Berg Balance Test.

Berg Balance Scale

What is the Purpose of Intervention? – 2. Tuning the Body

Consider the analogy of human motion as similar to music made from a guitar. Music is the product, the result of the individual components of the guitar working together. A guitar must be tuned, as it is this tuning that establishes the relationships and hierarchies of musical notes available to the performer. Notes that are required for the music may not be available on a guitar that is out of tune. This puts real mechanical strain on the performer and guitar. A guitar that is out of tune will burden the performer as they search for awkward positions to find the needed note to support the performance. The guitar cannot readily adapt and will likely experience some break down over time as the same strings are played over and over again and other strings are left untouched as they cannot support the music being played. The performer will find strain and bad habits produced as the guitar is not an efficient instrument.

However tune the instrument and all notes become available and easy to locate to the trained musician. Music with higher levels of complexity are attainable with this tuned instrument. In the human body, this change is seen during interventions for increasing mobility and stability. There is the mechanical change, and there is also the critical neurological change if the new available ROM or position is to be utilized by the nervous system. As the human body has greater coordination and consolidation of basic movement patters, higher levels of complex movement are available. Change when performed within the context of the hierarchical arrangement of the movements available in the body will result in long term capacity and on-going renewal of the body as it responds to the forces by building increasing strength and capacity.

Interventions are more successful in this structure. Using the movement curriculum, an inadequate performance on a contributing body segment can be seen as a remediation opportunity. Performance has been inadequate and after an assessment of the underlying causes of the inadequacies, a re-teaching occurs, providing valuable motor learning. This is critical as it is changes in the nervous system that are being corrected as well as at the muscle and joint level. Without the context, the unsupported movement patterns that have been “learned” by the nervous system will continue to be produced with only correction of the joint.
One of the dominant notions has been that of the intervention as a tool of correction to restore function. The notion is that full function is just on the other side of the wall that is limiting the function capacity of the patient. Break through and eliminate the impairment and function will be restored.

Spontaneous return of function after the “releasing” of impairment
Vs.
Availability of body segments to support the hierarchy of critical tasks that support the COG and BOS relationship.

Here is a thought experiment to consider for the movement professional. Both of the above statements refer to increasing mobility of a segment or joint. A successful intervention will make a motion available to the brain. How is the brain to use this available motion? If the brain is seeking a functional outcome the COG BOS relationship will be dominant. As a result that motion will be employed on behalf of the COG BOS relationship.

More mobility at a joint is not always the desired result, if that new motion does not support the other component levels. An example is ankle dorsiflexion for ambulation of a patient with neurologic weakness. Dorsiflexion is part of the critical task of the tibial anterior translation during the loading response into stance phase. In the well organized extremity, adequate dorsiflexion promotes the translation which is controlled via quadriceps and gluteal control of the lower extremity. In the case of a weakened lower extremity, it may be the best course of action to allow the ankle mobility to become less than fully mobile, promoting improved control of the anterior tibial translation. How much is a judgement call by the rehabilitation professional as it is essential to understand the role of dorsiflexion on the foots capacity to form an adequate BOS. To release the gastroc soleus to full mobility would undermine the function. Seen within the context of the functional result desired and the critical tasks that support the COG BOS relationship, the clinician is better positioned to intervene on behalf of improved function.

To make an intervention from a place of clarity of cause and effect and a clear observation without the assumptions of what should occur is a firm footing for producing the change effort desired by the patient.

What Is the Purpose of the Intervention? – 1. The Role of Structures

Rehab professionals  speak of treatment interventions as corrective actions. Picture a body segment that is out of position, not moving right, burdened by a problem of stiffness, weakness, or something that is stopping it from working correctly. This then is the stimulus for the actions that will take place, to change the bent to straight, or the straight to bent. With this accomplished the change effort ends and the collaboration between patient and therapist is completed.  Too often however the functional gains are not sustained.  The initial change is followed by a decrease in corrective actions.  Only after the complaint gets to intolerable levels again does the patient/client take action.

What is going on here is the problem solving structure that is being used results in less action as the intensity of the problem decreases. The structural approach and strategic organizing of the plan of care will impact how the interventions are employed. A problem solving structure to get rid of the problem is not a bad choice. However it may be an inadequate structure if the level of function that is desired is not at the current level of the patient.If this is the case, then a different, more robust structure to support many changes over time is needed.

It is helpful to understand the anatomic structure of a body segment, as this is the underlying cause of the function of that segment. It is also helpful to understand how the underlying structure of the plan of care impacts how the change effort will proceed. For the rehab and performance specialist focused on changing function, knowledge of how that body segment will move in different kinetic chains locally is important to understand what outcome is desired. How this movement contributes to the support of critical tasks that are occurring in support of functional movement puts the local movement on the segment into context of the whole body activity. This requires a framework to provide perspective and context of how the body segment contributes to function.

Corrections are done within the context of the body positions required to perform the critical task. The correction is either a mobilization to promote increased motion or stabilizing to promote control. This correction is dependent upon the hierarchically ranked critical tasks. At one point, the knee maybe needing greater mobility, as in the critical task of establishing the base for the sit to stand movement. At another time the knee needs greater stability to accept the body weight shift in asymmetrical stance. It is worth pointing out that it is the influence of the hip that will determine how the knee behaves. To simply focus on interventions that are local to a joint without the context of how that joint is influenced by other joints and its impact in turn is to miss the point. Within a framework that identifies these internal relationships, choices regarding intervention can be more focused.

The change effort also takes place on multiple levels of the hierarchy of function and the underlying body structure.  Interventions are different at the highest level of function.  This level includes the patient/client having knowledge and being apply knowledge about the functional movements.  An example of this is the patient being able to self assess function, and identify changes away from functional limits that increase risk of injury.  A patient with knowledge of the connection between sit to stand to sit completion and overall fall risk as it relates to choosing appropriate equipment for safety is well positioned to maintain safe functional movement.   As function is supported by critical tasks and the body postures required to accomplish these tasks, interventions become more specific and focused.  This hierarchical intervention allows for a granularity of understanding by the clinician, promoting the specific application of an intervention.

This is the difference between technicians and clinicians. Technicians employ interventions or perform data collection from standardized tests. Their focus is on process, on following the directions. A competent technician is invaluable to the clinician, as the clinician can trust the data before and after the intervention is accurate.   The role of the clinician is to interpret that data, look for relationships, seek to understand cause and effect and make choices about what is to be done next. Clarification of current reality is critical for the clinician. The testing maybe reproduced confirming the results. Or if something different occurs, the collaborative conversation can begin about what is being seen. Perhaps an intervention is not required after all.

Interventions that are borne of choices that take account of the internal relationships of movement and the hierarchies that exist in human movement are well positioned to support needed motor learning. The intervention makes available to the nervous system the body positions and body motions so that the brain can utilize these when organizing movement. When we mobilize a joint, it is only of benefit if it supports a critical task. When we perform soft tissue mobilization to lengthen a muscle, it is only valuable if the new motion promotes the completion of the critical task, and the antagonist of the muscle is better able to perform in the context of a critical task. With context as part of the decision making process, a successful change effort can occur.

Movement Professional as Educator: 3. The Educator

We have already explored the mind of the learner and the deviations that can happen when a framework for assessment and orientation is not present. What about the instructor without a curriculum to provide guidance? What do professional educators know about their own learning, their own self-assessment that is valuable to the movement professional?

In this case it is the mind of the clinician we will observe. When a clinician enters the room to collaborate with a patient or client, the clinician brings their assumptions, worldviews, values and other mental constructs. Often it is the clinical model that is the star of the show, as the clinician employs the techniques and skills of their trade in gathering information to provide clear diagnoses. With diagnoses in hand, the prescription is set and the problem solving can begin until the problem is eliminated. This problem solving framework is how much of the education system has trained practicing clinicians.

Contrast that with the patient taking center stage. What does the patient want in terms of a result? From these conversations, a specific outcome or results can be identified and the resources, decisions, skills and focus is organized around this specific result. At this point, a new framework is required to work in, that will bring about the desired level of function, to support the strategic choices required over a period of time to bring about the desired changes. Process now becomes focused, in support of a specific result. Given that the end result is now the organizing principle; a process that does not support the end result will be modified or even abandoned as convention makes way for invention. What is driving this effort? The end result.

Here is the thing. You can’t problem solve your way to the desired level of function. Why? You can solve all of your patient’s problems and alleviate all of their impairments, but they still will not be able to function if the motor learning has not occurred to employ the new ranges of motion, the new strength on behalf of the level of function. They still will not be able to produce the motions that are required if they have not learned the specific motions to support the specific result.

With a curriculum that provides depth and breadth, with internal relationships that provide a place to go during the learning process, the educator is focused on the end result. With the tools available for assessment, clarity about where the educator is in relation to where they need to be in terms of grasp of knowledge, application of skills, analysis of cause and effect, decision making and designing programs can be clearly determined. Through collaboration with professional educators, movement professionals can improve the educating skills and aptitudes that improve their clients and patients involvement in life. With a robust curriculum and lesson strategies, the impact the choices and actions made to improve movement will be long lasting and continuing to make an impact long after the learning is done.

Movement Professional as Educator: 2. The Students Mind

To have a deeper insight into how apparently disparate parts of information impact each other is one of the hallmarks of real learning. Relationship seeking, cause and effect driven structures as they are our minds can use this information to take action on desired results and make the outcomes that did not previously exist. And yes, old dogs can learn new tricks. However learning something new can be fear producing in many students. A student by definition is beginning at a place of not knowing. And as was discussed in the first article of the series, the mind does not care for this state. In fact it will make things up to alleviate the discomfort of not knowing. Good students typically have developed a tolerance to this state of the unknown. A competent educator knows how to use the potential energy available to support the change effort that the student is presenting.

The task of the educator is to create a new structure for the mind to explore cause and effect. An underlying structure of a clear outcome and an adequate understanding on the student’s current knowledge and capacity levels in relationships to the outcome produces a clear path to learning. Structure is causal. It has tendencies and the use of different structures in the plan of care will result in specific outcomes. It is the educators’ choices that will determine the structure to be used and the forces in play generated by the structure.
In this way, the educator is an architect, building the structure for the mind to step into, to begin exploring. The new structure, like a jungle gym provides the mind with the chance to begin to see new possibilities, learn new skills and shift its perspectives. The curriculum is more than just a collection of facts and knowledge to be presented. A well-developed curriculum is three dimensional, with internal relationships. It is hierarchical in that there is complexity at that top that is supported by lower levels of complexity and difficulty. It explicitly and implicitly demonstrates cause and effect. With this insight the learner is able to become the causative factor in their lives, as they seek to make choices to reorganize the materials on hand towards more of what is desired and take actions that are measurable in terms of their impact.

What differentiates competent educators with the newbies and wannabies? Is it the grasp of the knowledge they were presenting? Maybe a background rich with experiences to highlight and explain the content presented in the real wold? All helpful, but what really is the key the skill to assess the state of learning of the student. It takes the educator to have not only a clear understanding of the curriculum and its component parts but also how to assess the state of learning of the student in relation to the behaviors, skills, and aptitudes within the curriculum. With these two complimentary data points of where the student wants to go in terms of the curriculum and where they are now, a real dynamic is produced to activate the change effort. The quality of the measurement tools used by the educator will impact the clarity of current reality. Standardized screening and assessments produces reproducible and credible data that supports the change effort to come.
Again, the movement professional will see similarities when teaching lessons of movement. Whatever philosophy the curriculum is rooted in, whether yoga, Pilates, biomechanics, or insert your favorite approaches here, it must include an effective assessment component. Otherwise the learning loses steam when things get tough. Focus is lost and the mind does what the mind does. In this case find something else easier to try and the collaborative effort is lost as the learner becomes unavailable for learning.

Through the collaborative effort the student has the opportunity to examine the sequencing and role that there clinical decision making made on the outcome with the instructor. It is the student’s role to do the heavy lifting in thinking it through. This is sometimes an insurmountable task and always a task that is challenging. When it is too much it is the educator’s role to know how to reorganize the learning in a way that the learner will develop the knowledge, skill, aptitude necessary to move to the next step. Sometimes it requires stepping down and re-consolidating to form a more firm foundation to take the next step up. As movement educators we need to know how to regress the movement lesson into a lower level of complexity and find the area that is in need of remediation. This is done through the ability to produce smaller components and granularity in your movement curriculum.

Here is the good news. In education, much of the designing of learning as change efforts has been researched and understood. There are a number of different approaches, such as Blooms Taxonomy and many others, which organize actions and behaviors into hierarchies. In much the same way, the movement curriculum presented in the Structured Motion courses is organized to present a clear outcome and how it relates to higher more difficult levels of movement. As stated earlier, curriculum is not of much use unless the student and instructor activate it through the assessment of the student’s current level of learning. Through using both data points, the learner is well positioned to gain the skills and knowledge to be involved in their life.

Movement Professional as Educator: 1. The Job to Be Done

Education requires more than the ability to retain and recite facts and figures.  The days of the stern task master, focused on route memory are well behind us.  Educators have many roles, many tasks to perform on behalf of learning.  Movement professionals in rehabilitation and sports performance are educators. What can the fields of academic learning teach to the movement professionals about creating motor learning? Years of educating has produced clarity about the work to be done and who is accountable for what in the student-instructor relationship. Clarity on the roles and skills required for both will produce the dynamic required for needed learning and for the desired changes on behalf of the learner. For educators, it is important to know also what the student is accountable to produce.

It is not the job of the educator to take the action for the student. And it is certainly not the role to do the learning for the student. Clearly, it is not the job to motivate the student. Nor is it the job to organize the student’s choices for them. There are a number of jobs that are not the movement professionals, and these are a few of them. These are the realm of the student.
The work to be done as an educator is to organize the environment to support the learning of the student. Making assessments about the state of learning, and making choices about presentation of information, all are critical to developing a successful change effort.

The successful movement educator has not only a grasp of the facts and figures, the knowledge base, but also how to arrange that knowledge into focused movement choices. A Physical Therapist for example is not responsible to do the exercises, learn the movements, and choose to move differently for the patient. It is the role of the PT to setup the plan of care and subsequent treatment lessons in a way that promotes not only cognitive learning, but motor learning. And just as professional educators can attest to, more than just a grasp of knowledge is required for real learning to occur.
This can be news to the professional who has viewed him or herself as solely a fixer, a mechanic, a changer of muscles and joints. More likely the movement professional sees the need but was not educated as an educator and as a result is not aware of the curriculum building process, the lesson development approach and the impact that structuring learning has on long term acquisition of skill. A well-developed curriculum provides the framework that I described above. Providing footholds and hand holds for exploration of knowledge and development of skills.

Educators are also are performers, as a presenters of information. To make it interesting for the audience of learners it is important to engage with the learner, to focus the attention. Learners that are clear about how the information will impact their lives and how the information, skill, aptitude is on behalf of something that matters to them are interested. Presentation that includes the learner, asking them to interact with them as the information is presented; asking for their feedback promotes higher levels of the brain. Content that is more contextual for them based on my understanding of their backgrounds and experiences brings in prior learning that can build upon.
The same is true when working with a patient or client. Promoting the clear understanding of how this movement skill impacts their life and how improving their movement choices will provide them more involvement in life as they desire.

What really draws the learner in is to have the cause and effect explained, to have a deeper insight into how apparently disparate parts of information impact each other. Our minds are relationship seeking, cause and effect driven structures. Given the opportunity, a mind will gnaw on a problem, seek to understand what happened and keep chewing away on a problem like a dog chewing on a bone until the mind is satisfied that it understands. Another way to look at this inherent ability of the mind to seek understanding is the behavior associated with a state of not knowing. With enough plausibility the mind will create false, fictitious explanations to release the tension associated with not knowing. Although not true the mind will hold on to that explanation, again like the dog protecting its bone. Ever try to take a dogs bone away…probably was the last time you tried. However, create a new structure for the mind to explore cause and effect and begin to let go of old ideas as it reaches out to new hand holds on the structures and real learning can take place.

In the next article the students mind and tendencies when learning are discussed. It takes more than just understanding what is to be taught to the student, to produce a successful outcome. The values supporting this approach is a desire to see the learner involved in their life as they choose, and to have the capacity to perform at a level that matters to them. In this way the educator impacts more than just the learner, but through extension, the learners’ impact on the community.

Practice Management

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