In the previous article, the question was asked “How often today do PTs, OTs and other providers asses a person’s ability to stand up from a seated position as poor and then make the conclusion that what is needed is more lower extremity strength?” In a problems solving structure, the clinical decision making lead to exercises prescribed to improve strength. It would likely include some open kinetic chain exercises as well as Continue reading Structured Motion Approach – 6. Critical Tasks
Structured Motion Approach – 5. COG BOS and Imposed Demands
We ended the previous installment with an introduction of the star of the show, the COG and BOS relationship. The article also introduced the notion that this relationship was determinant, in other words it would be the most influential on function. This article continues to develop the point and sets the stage for the change efforts in upcoming installments.
Each of the different COG BOS relationships is imposing a new demand on the neuromuscular system as the kinetic energy is increased as the COG moves away from the BOS and the need for the production of internal stability is increased as the BOS changes to a less stable form. Within each of these snap shots in time of the COGBOS relationship, there are Continue reading Structured Motion Approach – 5. COG BOS and Imposed Demands
Structured Motion Approach – 4. Performance Skills
In the previous installments, a number of introductory components of the Structured Motion approach have been described. Starting with a focus on making specific results, the client or patient is then engaged to ensure that the result being made is really what is wanted by the patient or client. As part of being an expert in the field, it is easy to decide for the patient or client what they should want. It is also important, given that these processes and actions are expressions of the value of freedom, that the patient be a collaborator in the outcome. This is an active process of collaboration in which the client or patient identifies what they want and the professional organizes around that outcome. Included in this is the freedom of the patient to not accept the intervention by the rehab professional. It is essential that the client or patient is choosing to be involved, and choosing to act on behalf of their involvement in life. If the client or patient refuses service, then further referrals to the appropriate professional can be made. It has been our experience that there are different levels of desired involvement in life. This is different than depression or a withdrawing which again would require a referral to the appropriate provider. It is this initial process of organization by the professional that will be introduced in this article.
At this point a report that presents the comparison of the desired level of function as identified by the client and the current levels of ability is generated to assist in the assessment process. Each specific activity identified will have one or more performance skills category which includes those movements that observable. These are typically what is referred as functional movements. These movements are often tested using standardized testing such as the berg test. Examples include: sitting and standing, turning in a circle, reaching for something on the floor and a host of many more functional activities. These movements become the entry point into the assessment of the person’s ability to perform the desired specific activities identified earlier. These performance skills are more than just movements on a macro scale, but are really movement strategies of the brain in orchestrating the body to manipulate the COG BOS relationship. All motion includes the controlling of the COG either statically or dynamically in an ever changing BOS.
The movement skills are further defined in terms of the COG and BOS relationship within the observable Performance skill category. For example within the category of bridging, the COG will start out in the BOS which is the length of the body as the person is resting in supine. The BOS will then change to a 3 point of both feet on the ground and the trunk as the person attains hook lying position. The COG then is dynamic as the body raises the COG above the 3 point BOS and the BOS further changes from the trunk to only the upper spine, scapulae, neck and head in contact. After attaining maximal rise, the lowering begins, requiring a different muscle contraction and level of control, until the beginning level is returned to.
This clarification of the functional movement as it relates to the desired specific activity and its related definition of COG and BOS relationship provides a framework in which the COG and BOS relationship will be present throughout the assessment, evaluation, and change effort. In this way questions regarding the impact of an intervention on body movement or posture can be compared with its result on the COG BOS relationship as it will determine the functional involvement in the desired activity.
Structured Motion Approach – 3. The Desired End Result
It starts with the level of function the client is seeking. Again, for those who have been part of the movement professional community, this can be an abrupt change from the typical seek and destroy mission that is organized around what problem to get rid of. Pain and loss of function will certainly be addressed; however without the context of an overall desired level of function, something specific, the change effort is likely to end when the pain or problem intensity subsides. Identifying patient’s true aspirations is done through a survey of the in regards to activities the patient or client wants to be involved in. A quick assessment of the life categories helps to identify where the focus will be, as areas that are deemed adequate can be reviewed but not assessed specifically. After the client has chosen a few of the specific activities that interest them, they are asked to self asses their current abilities by choosing similar tasks that are associated with varying levels of difficulty. These levels may be defined as a different performance skill that is required, a different energy level required of both.
This first action is asking the patient or client what really matters to them may seem trivial, a nicety, and window dressing to the real work to come. The purpose of this exercise in identifying true aspirations is to generate the momentum and interest in the work to come. Frequently in a problem solving structure in which the expert is the provider and giver of the solution, the patient or client becomes passive. It’s not their fault, as they are simply reacting to the implied expectations that it is their job to be a passive participant. By asking for what is desired, the foundation for true involvement is set. However it is not enough to know where they want to go. We also need to know where they are now. This observation and recording of where the patient status is now in relation to the desired outcome is the work to be done. It begins with the client taking the first steps.
The client then performs an assessment of their general mobility capabilities. This is done through the client being instructed to perform a series of motions in different BOS. Supine, seated, squatting, standing in a stride stance, and standing on one leg are progressively requested depending on the prior, simpler levels answers to the question. The client selects from 5-7 different descriptions of the action performed and asked to select that description that most closely describes their ability at that time. This progression is for safety as it is reasonable to conclude that a person who cannot sit unassisted is unlikely to be able to stand without significant need of assistance. In addition, it is reasonable to conclude that client with this scoring would be in danger if asked to perform a stride stance balance test or a single limb balance test. As a result those tests are only offered to those who are able to demonstrate an acceptable lower level score.
After the conclusion of the mobility test, a self-test of aerobic capacity is performed. For those with low mobility scores, the aerobic survey is presented for completion. This self-survey provides a reasonable approximation of aerobic function. Starting with this allows those with potential for unsafe movement to provide data but not be at risk. For those with higher level scores on the mobility screen, both the aerobic survey and a 6 minute walk test is performed. Both forms are presented to the user and the appropriate check boxes are made for the aerobic survey and data added to the requested text boxes. The program then calculates the scores and presents the MET levels.
After this is completed a report is presented that demonstrates the results of the mobility test and what are the percentiles for that movement pattern. Also the MET scores are presented. A separate report is presented with a clickable list of acceptable activities for the person to perform based on both their mobility scores and MET levels. This list is life area specific. This list is provided in response to the question “What can I do now, given my current functional capacity.” This offering is a direct expression of the value of involvement that our company holds as an organizing principle. Why wait to encourage involvement? Regardless of the level of capacity, many life activities can be presented as reasonable ways to get involved.
The report also presents the comparison of the desired level of function as identified by the client and the current levels of ability. The general mobility and MET level is compared to the tasks and energy requirements of the function and a recommendation regarding current ability is presented. If the general mobility and MET levels are lower than the desired levels, the change effort will include remediation of lower levels. If the current levels are greater than the desired levels then the user is exempted from those lower level activities. At this point the specific desire results can be investigated for physical capacity to perform and a change effort presented for the user to develop maximal capacity. An example of a user with higher level of current ability still requiring education on lower levels would look like the following. A user wants to be able to sit and work at the computer for extended periods of time and is currently able to pass all components of the general mobility and 6 minute walk test indicates a MET level of 10.5. The seated activity requires a MET level of 2.3 for example. The lesson presented would include supine chop lift, seated hip hinge with core integration and squat progressions all to assist in maximizing seated postural ability.
Why use these exercises…Structured Motion is about intensification of functional movements. With this approach a strong foundation of actions on behalf of the patient or clients goals are initiated. The upcoming installments will describe how the change effort progresses and the focus on creating a specific outcome.
Structured Motion Approach – 2. Current Practice Patterns
Submitted by: Jeremy Nelson PT
In the previous installment, Structured Motion as an approach to restoring function and improving sports performance was introduced. As an investigation and application of clinical decision making strategy and the relationships of component parts of the decision it includes contributions from many seemingly unrelated fields. The arts, business, and other fields of making provide the investigation of the underlying structure of the plan of care itself. With a change of underlying structure, the impact on the outcomes were examined. In particular the capacity to change perspective in supporting the clinician to step in for a close up of the specific motions required for a joint to perform as well as gain perspective by stepping back to see how that motion is impacting the overall function. This is supported not only by a knowledge base of human anatomy and kinesiology. The role of decision making and the different ways the mind reacts to states of unknown.
Too often, as a result of the underlying structure of the plans of care developed, perspective and context is lost as the breadth and depth of the plan of care is inadequate to support the clinical decision making process. Within a standard problem solving model, the outcome is unattainable as the change effort leads to loss of momentum and a return to level of function that promotes recidivism. Using a problems solving structure, the relationship between the numerous data points required to produce a successful change effort are unrecognized and as a result the clinical decision making becomes formulaic and process driven. One process leads to the next until all processes are completed, regardless of the status change of the client in relation to the desired outcome. Short term goals are unrelated to outcomes and are poorly defined, in such that clinical observations of the state of the patient in relation to the goals are difficult to establish.
Why does this happen? When considering the numerous data points and relationships that are required to observe and understand when working with human motion, it is easy to see how the clinician could become overwhelmed by information. In light of not knowing, the mind will do a very natural thing and fill in the gap with previous conclusions and assumptions. The question “Am I seeing what is happening in front of me accurately?” is not asked. The motivation for such a clarification question is absent as the mind assumes that what was true in the past is the reality of what is being observed. On occasion this may be true, however given the wide ranges of human motions and neuromuscular status the past is unlikely to be in the present. The rehab professional comes by this approach honestly as the training received is in improving categorization and not necessarily thinking.
The relationships in the goals are key, however it is the support of the ongoing clinical observations that is engine for the development of a successful change effort. Through an on-going assessment of the state of function and supporting components a clear understanding of the cause and effect relationships is established to support more efficient decision making towards the unique specific outcomes desired by the client or patient. With this relationship of the desired outcome and a clear assessment of the current reality of the patients function in relation to the goal, a new structure is in play that will provide the momentum to complete a change effort over time on behalf of the patients or clients desired level of involvement in their life.
Lessons of Function
Submitted by: Jeremy Nelson PT
Human function is about orchestrated movement. The brain, with a vision or urge, or notion of what is desired utilizes the dynamic relationship of a fixed COG and an ever-changing BOS. The combination of muscle, joint flexibility and strength and the unique proportion of the human form produce a tendency to movement. Not all movement is equal in its production of force. Given a circumstances of inadequate positioning or power, the body will tend to compensatory movement in which the component performs movements that it’s structure cannot handle. However the brain will seek to control the COG and BOS relationship above all else, causing parts to contort and strain to get the job done. Often it looks awkward and inefficient.
Functional movement on the other hand is progressive. The components work together in a supportive way. We need to sit before we can stand, and stand before we can walk. This is not a new notion. Neurodevelopmental and pattern approaches have harnessed this idea. The idea is to use one body position before another to provide a progressive and regressive capacity to change efforts. However the patterns are in support of changing the relationship between the COG and the BOS, and in that way the brain is able to control the forces in play. The stored kinetic energy that the proportions of the human form produce and the reactionary forces in the environment are available to the brain to move from one place to another.
When viewed in this way, human functional movement is seen on a continuum. The continuum is a relationship between COG and BOS and the increasingly more complex coordination of the body as the COG rises higher above the BOS, and the BOS narrows more and more to a point. This continuum is also hierarchical, like a staircase where one pattern is in support of more complex patterns of movement, and in turn maybe supported by simpler COG/BOS relationships. We can name these steps based on the patterns of movement observed.
Change the BOS and a new pattern emerges as the relationship of the COG and BOS changes. A split squat position is still a squat however it is a higher level of complexity as the BOS is now a parallelogram shape and not a rectangle. The split squat promotes the use of a diagonal and thus assists in weight shifting, supporting a greater level of functional movements. As this complexity increases the capacity of the body to handle what the world will throw at it, whether it is uneven surfaces, low seated positions, quick changes in speeds or directions.
I think this distinction matters, because it’s easy to see role of the professional clinician as a problem solver eliminating sore muscles and stiff joints and not a builder of capacity. Within in our hands is the key to function, only through our touch will the patient be improved. This external view is left over from the paternal medical models of treating patients to heal them. Its clear now that the patient is doing the healing, and the rehab professional is there to find the way on behalf of the patient. Our role is to not only change flexibility and motion but to move our patients up the continuum of function. Similar to an educator I choose to establish lessons for the brain to orchestrate these movements with greater efficiency and effectiveness. As the patient progresses along the curriculum the therapist is guiding the lessons, assessing what areas needing remediation, knowing that each lesson builds from the previous learning.
Without this ongoing assessment and clarity of the needed critical tasks to support functional movement, compensatory movement returns. With the successful graduation through the rehab or performance lessons, the patient or client has a new found capacity to sustainably be involved in life as they desire.
Learning from Artists
Submitted by: Jeremy Nelson MPT
If its our job to make a plan of care, to orchestrate changes over a period time that will cause the structure of our client to be able to perform better, why not look to the knowledge bases and skill sets of other makers to see if we can learn something. Music composers, strategic planners, choreographers, architects, and other professions of the arts. In particular the training they receive in the being professional makers or creators. All develop arrangements of interrelated parts that give rise to specific results, whether the medium for the artist is sound, light, space, or color.
The subject matter that the rehab and sports performance professional works in is that of human motion. What is there to be learned by the professional artist that consistently produces specific works of art, sometimes requiring weeks, months or years to complete the work. How do they organize their work and change efforts? Is it something that can be applied to the work of improving human function and performance? A little background on the on going investigation of producing specific results in the realm of physical therapy is presented in the following paragraphs.
Many years ago, as a shiny new PT I worked for one of the big rehab providers that were dominant in the rehabilitation market during the 1990’s. This was the time of Managed Care and by the late 90’s providers, regulators and the consumers were beginning to push back having been pushed around by the often indisputable decisions of HMO’s and other managed care organizations. The whole focus was on reducing costs, which was coming from a focus on the problem of increasing health care costs. Make the system more efficient because of the problem of waste. Too much out of control costs were threatening to ruin the future. The action was to rope in these out of control costs or bad things would happen.
As a result, this general policy was being applied in large generalizations based on diagnoses, DRG’s and other attempts to find accounting hand holds will deciding how to allocate the healthcare dollars. The principle was that pathology could be categorized and the patient assigned to a general category of pathology that would be associated with best practices, care paths, and reasonable costs. Certainly a logical consideration when working from within the problem solving structure. However this was to set up a conflict based on values that change healthcare as we know it today.
What they were seeing was through bottom lining each diagnoses, patients could be categorized and treatment plans standardized to off the shelf pathways. What myself and my colleagues were seeing was something different. What we collectively understood was that each patient is unique and their circumstance more than just their diagnoses. Often times patients with the same diagnoses presented very differently in terms of their needs for functional restoration and the services of a rehab professional. As a result, pathways were unsupportive in providing guidance. More categorization on a sub categorization level was prescribed and diagnoses were divided again and again adding to the complexity.
This was all taking place within the context of one of the few remaining centralized hospitals for rehab services. At one time, novice rehab professional, the land was full of rehabilitation hospitals, dedicated to restoring function over weeks to months. Today, the goal of full rehabilitation before returning to the community is unlikely. The pressures were immense for a large organization to try and manage the limited reimbursements from patients that required reasonable resources. But again we were up against a system that was grouping patients by diagnoses.
The FOR – Functional Outcome Report
With support from my colleagues in the rehab department we started to develop a tool, a communication tool, to provide information to the insurance adjusters that presented the patient unique situation. Using the Nagi model as a basis, the report sought to demonstrate the unique levels of function of the patient and in relation to the needed levels of activity to return home. With this slingshot we took on Goliath. Well it didn’t turn out the way I thought it would, namely the development of the tool as an on-going part of the medical record. But it did clarify in my mind that as a patient advocate, the place to start was with an honest assessment of the current capacity of the patient and trying to describe it within the context of the physical demands that would be required to re-enter the community.
In this way, perspective was developed that could assist in decision making. No longer would I be focused on the diagnoses as the primary organizing data point to my plan of care and actions. Now don’t get me wrong, I am not anti pathway, nor do I rail against the evils of protocols. These are valuable and necessary tools. What has changed with most pathways is that the sequentially organized outcomes are defined in a way were they can be measured. For it’s the assessment of current reality that changes the pathway from route process to a tool for clinical decision making. However, event this addition of a clear current reality and what the outcome is supposed to look like will not be enough to support the long term change efforts associated with most rehabilitation and sports performance improvement. For that we need to understand what the professionals who work for weeks, months, and years in producing a work of art, a composition, a software project or other structure that is interacted with.
Better Forms of Problem Solving.
After I changed organizations, I was involved with the task of improving efficiencies for an organization I was employed by. It seemed simple again, build a better system of patient care and the world will beat a path to our door. Before I began studying structures, patterns and the dynamics creates by structural relationships, I continued with experimenting with various classifications systems, now with the power of relational databases. However as I would learn later, classifying is not creating nor is classifying the same as clinical decision making. I now had a more robust system of sorting data and repeatable logic in the form of a computerized database.
This type of “If Then” thinking seemed like the approach to take at the time. But again I bumped up against my preoccupation with the specific. No classification system could encompass all possibilities, given that all patients had unique circumstances, desired outcomes, capacities and environmental constraints. And even if it could, the data structure would not be able to handle the human element of values. Within the context of the specific, one element of the decision may outweigh all of the other considerations. It seemed that trying to produce a better problem solving approach was limiting what we could provide and was working against the customization and patient focus that we were telling our community that we valued as an organization.
It’s worth repeating that the practice of improving and restoring function is an act of making, of building. There may be some tasks that require the elimination of something but it’s always in support of some sort of specific outcome or behavior. You can eliminate the pain in a joint and still not have an arm that can throw a ball. You can restore the flexibility of the lower extremities and still not have someone who can walk safely. I think Robert Fritz has said it best, “You can get rid of all of your problems, and still not have what you want.”
Although I could see the need to be able to make things and my role as a PT as a maker of body structures that would give rise to functional patterns, I was not very good at it. I came by that poor performance honestly as I was simply applying the wrong causal structure to produce the changes that I wanted. Most of the time the pattern was to make a big effort, see change in my patient, and then have that patient return in a few months with the same problem and then to take massive effort again in dealing with the crisis. I understood bio mechanics but faced with the multiple data points and complexity of moving parts it was difficult to organize the information into a narrative of actions taken over time to improve function. Often time, the patient and myself would know that an outcome was wanted in terms of returning to the golf course after the back injury, or beginning tennis after the shoulder pain, but the action would sort of run out of steam.
Over the years I have been amazed at the complexity of functional movement. When the hierarchical arrangement of the body and the smaller movements that support the larger functional patterns are superimposed on the complexity of movement, it becomes much less complicated. As I continued to study the different fields of art and the knowledge base and skill sets of composers, painters, and other makers, I learned that the highly complex is an arrangement of simple relationships. These simple relationships act as a basic unit of measure that can be organized in higher levels of hierarchical arrangement.
Whether it is a Bach fugue or a Picasso, the fundamental relationships are present. It wasn’t until I began studying system dynamics and structural dynamics that I began to learn that the cause of the problem is not always at the site of the symptoms. Also, I learned through the study of Structural Dynamics, that the arrangement of outcome and the current reality assessment of the outcome can produce a new dynamic to restore momentum when the energy had gone out of the project. This was a tool of the trade for professional makers, as they would step into their work, producing and making, and then step back to get a clear perspective of how it was progressing in relation to the vision of the work.
Structure is found also in the subject matter of artists. Musicians work in a world of proportionally related sounds. This scale of sounds and their internal relationships provide the foundation for the development of music. Music includes rhythm, melody and other observable behaviors. If the sounds were not prior related, it would be impossible to produce music. For these scales hold in them the ability to produce tensions, tensions that come from the arrangement of opposite but complementary musical notes.
The human body also contains proportions and a hierarchy of arrangement. The body is a series of interrelated components of a whole, each with a supportive function towards a functional outcome. We can use this underlying proportional structure to produce intensification of functional movement we call therapeutic exercises. Not all therapeutic exercise are created equal. Just as a wrong note to ruin the momentum and capacity for expression in a piece of music, so can including an exercise that undermines the function of the component as it supports the COG BOS primary relationships.
Artists and other makers have specific skill sets and knowledge bases. They have unique sets of knowledge, however they have the commonality of organizing their workflow to produce long term change over time. With an understanding of how to make things, the rehab and sports performance professional can add this skill to their change efforts, providing more opportunity for the change that clients and patients want to be involved in their lives as they desire.
A Question of Questions
Submitted by: Jeremy Nelson MPT
It might be time to upgrade the quality of your questions that you are using in your practice. Questions are wonderful tools to produce results. Through the organization of the thought process as related to underlying observations, a structure is formed that promotes investigation and observation. Just like drawing the bow before shooting an arrow, questions build the energy necessary for action. How much energy and to what direction have to do with the question itself. Questions like tools have a structure, a form that supports its behavior and the behavior of the person using it.
When you use comparative thinking you ask certain questions that assume the answer. When using comparative thinking of “like this, like that” there is an underlying assumption. These assumptions are what Robert Fritz describes as “other than reality”, and are instead concepts about the relationship of things and as a result cause and effect. Here is an example of a question based on comparative thinking: “What muscle weakness is causing the difficult to go from sitting to standing for this patient?” Not a bad question, but it does introduce some variables into the clinical decision making process that may not be there.
Already there is an assumption that the person cannot stand because of weakness. It may also include memories of other patients that had lower extremity weakness. A quick look at the knowledge base to query “What muscles are used in standing”, returns the usual lower extremity suspects. Has is this to be included in data that indicates the lower extremities are 5/5. In this structure established by the question, the conclusion would be to assume the extremities are not strong enough. What is really driving the action here is the unexamined assumption that it is an inadequate set of legs that are the cause of the problem.
Another way to describe this is short cut thinking. Based on the diagnosis, based on the demographics of the patient, based on a number of other data points, assumptions are introduced into the clinical decision making process. Often these underlying assumptions are taken as reality and are left unexamined. How is someone to know…by observing the movement.
So, if you have read a few of our other articles you may have done this, but its worth repeating the exercise. While seated, produce a posterior pelvic tilt. Maintain the posterior pelvic tilt and T/S kyphosis as you attempt to stand up. It should be impossible, even with your arms assisting.
How did this happen? Is this some sort of voodoo, causing your legs to no longer work? No, it’s simply an inadequate COG and BOS relationship. Even with daily lower extremity strengthening over many months, you still would not have the lower extremity strength to stand up. So, if we met this patient with our assumptions left at the door why a person would not be able to stand up, and instead began assessing their current posture, strength, mobility, against the desired outcome of a COG and BOS relationship that supported sitting and standing, we would have different questions to ask. Such as “given the observation that the COG is posterior to the BOS and the patient is not able to stand up, what position must the body take to restore the COG above the BOS?” Now our decisions are rooted in reality.
When you use original thinking you ask questions that seek to investigate cause and effect. Original thinking starts with understanding what is desired, what outcome we would like to create, and then making observations about how well the performance is now. From that structure, more focused questions arise. These questions are clarifying questions often seeking more information, that lead to more observation. They maybe questions that seek to make implications explicit and gain more information about what is being concluded. Or they may be questions that seek to understand conflicting statements better.
Now, what about the role of hypothesis in clinical decision making? Of making a conclusion and then testing it against your finding? This has been the supported approach to good science. However, it is simply a more sophisticated of conceptual thinking. Newton did not conclude that the apple fell based on gravity, but instead asked the question “Why did the apple fall?” As a result of his inquiry and investigation he created Calculus as a tool to better understand what was going on, given that he did not know. This story was explained by Robert Fritz again as he described the role of structural thinking and starting without assumptions about what is causative. In much of the reading found in the physical therapy journals, much of the research is to examine the existence of conclusions already made in the professional knowledge base in different populations of patients. This is different than organizing change over time to produce a desired result.
Again the difference between original thinking and comparative thinking is found in its outcome. Original thinking the type of thinking that leads to specific unique results and often includes process invention along with process convention will support the process of producing unique specific functional outcomes that includes the patients’ medical state and functional state. Comparative thinking begins with assumptions about how the world works, and then gathers evidence to support those assumptions. In this case the database includes diagnoses, what is expected with diagnoses and the likely outcomes, treatment approaches, etc.
What we are describing is not a new diagnostic model. Instead it is a learn able skill to observe what is there so that you are better able to create a specific outcome on behalf of your patient or clients goals. This is done through visual thinking, observation, asking questions that promote further investigation until it is clear how the structured is organized to give rise to the pattern of behavior. Beginning with best questions will improve the change effort and provide the clarity of cause and effect that will assist your patient in being involved in their life as they choose.
Planes, Boats, Bicycles and Bodies
Submitted by: Jeremy Nelson MPT
I was reading a book on engineering and design of bicycles not too long ago. Cycling had been a very big part of my life and I was interested in what gave a bike a certain “feel”. Another way to say was how the bicycle behaved over different circumstances, cornering, climbing, descending, sprinting. In other words why it functioned as it did. The more I read about the design process and the goal of changing the COG over the BOS of the bicycle with the addition of a rider, I recognized many of the same considerations in the practice of PT.
It’s as if the therapist is playing the role of the engineer, working on behalf of the brain, which is seeking to balance the forces created by the COG BOS relationship. The cerebral captain of the corporeal ship is always changing course, ordering the crew with an ongoing changes in the position of sails and rudder to stay the course, or react to changes in the environment. In a presentation, Robert Fritz describes the thoughts of Peter Senge who writes about the interaction of design and performance. Mr Fritz and Mr. Senge ask “Who has more influence on the ship, the captain or the ships designer?” After consideration of the role of cause and effect in how something behaves, they provide the answer: “It’s the ships designer as the design of the ship will determine how the ship moves through the water. ”
The role of the designer is to organize the ships form to create a distinct COM/COG and a BOS relationship that takes advantage of the natural forces of buoyancy. This is not a trivial task. Have you ever seen or been on a aircraft carrier? Every time I am looking over San Diego bay I see the aircraft carriers based in Coronado and wonder, how it is that these huge masses of metal float like corks in the water. And as a result provides a distinct functional capability that the captain organizes his decisions around.
As clinicians we have a role as a designer, an architect and engineer of a plan and actions to produce new relationships for the brain to utilitze. Each body, whose structural proportions are fixed, have interrelated components that move in relationship to each other to provide function. Change the relationships of COG and BOS relationships and new levels of performance are made available.
Likewise the re-structuring of the segments of the human form such that there is greater efficiencies in controlling the COG over a wider variety of BOS configurations. Each different organization of the COG and BOS imposes new demands on the brain to position the extremities and core in ways that maximize there capacities. If one area is inadequate to task, others are called upon to take more of the strain. This lack of component capacity limits the effectiveness of all the other parts of the neuromuscular structure.
Our body has proportions that also work to guide and direct forces, like the ship or the plane. Our body creates a tension, as does the planes structure. Based on the form of a ship or plane there is a zone of most efficiency when piloting these crafts, a path of least resistance for the operation of the ship. The structure of the vehicle creates a 3D zone of most available motions that are most efficient, that due to the structure of the vehicle can attenuate forces the best. Pilot these vehicles out of the zone and the structure are tested as shearing forces are created that can damage the structure and lead to failure.
Our human form has a path of least resistance that is seen in beauty of the spiral form, curves of motions, and ballet type moves of gracefulness. We are not linear in nature, robotic, prone to 2 degrees of freedom. Robots move with extremities acting in support themselves, while the human body is a continuous form, with all motion emanating from the core. When the brain is trying to shift the COG anteriorly over the BOS from an upright seated position in the sitting pattern what is going on under the hood is a changing of force. to maximize the kinetic energy such that the muscles can work efficiently to change the position of COG relative to the BOS.
When seen in this way, therapeutic exercise is no longer a focus on just correcting malposition’s, but become intensifications of the functional movements that are required to perform the functional task. In order to sit and stand, the hip hinge is used to translate the COG over the BOS to the position of most efficiency before standing up. The approach that thinks of the body as a summation of the strength and flexibility could conclude that the problem is inadequate LE strength and begin the process of LE ther ex to improve sit to stand ability. Returning to our ship analogy, if the COG is to high and the BOS is to narrow, the ship will be unsteady, and likely capsize because of the force of buoyancy. Planes need to have their wings positioned in relation to their COG to produce adequate lift to fly. If we though that the lack of flying was a strength issue, we would add a bigger engine creating greater forces on the frame of the plane and stressing the wings even more, possible to the point of failure. See, it’s not a strength issue, but an issue of COG and BOS.
One more, returning to the bike example we started with. By placing the COG of the bicycle and rider towards the rear of the bike, stability is increased and the bike has a smoother more relaxing ride. This is the type of bike that even a novice could ride with their hands off of the handle bars and safely cruise around. A rider participating in a race with many turns and need for fast acceleration would find this type of bike working against her. It would be difficult to make the turns and the rider would have to work extra to accelerate.
Now take the same rider, and put them on a bicycle which has a COG towards the front of the bike in relation and the rider will find themselves quickly cornering and accelerating out of each corner with ease. Now keep in mind, same rider, same strengths, and different bikes with all things equal other than the COG BOS relationship different. The point is that the COG BOS relationship is imposing different demands, and as a result the brain will have to reorganize its coordinated efforts to complete the tasks at hand.
As rehabilitation and performance professionals we often see our clients and patients performing awkward patterns of movement when trying to complete a task. As professionals we can misinterpret these compensations as areas of weakness, thinking it is the compensatory part that is to blame. We then go to work to correct the compensating area. However, if we ask what is happening at the COG BOS level to impose the demand on the body, we may then see that the area is attempting to make the COGBOS relationship work. Other areas are resulting in the inadequacies. Start with the COG and BOS relationship as dominant data points when organizing your change effort and you will find it is easier to understand what is causing the patients difficulty in being involved in their life as they desire.
An Introduction to the Structured Motion Approach
Submitted by: Jeremy Nelson MPT
About 8 years ago, my colleagues and I at Freedom In Motion began an investigation of the fundamental structure of rehabilitation and sports performance and how the application of different strategic planning approaches would enhance our practice. Motivated by a desire for our patients to have greater involvement in their life, we began to question the underlying assumptions found in treatment planning and treatment progressing. In particular I was interested to see if a change in underlying structure of a plan of care would change the outcomes. Along the way we invented new approaches to assessing movement and over the years a full curriculum of movement lessons to promote improvement in specific functional tasks and movements that we named Structured Motion.
Through this investigation we began to systematize the information we were learning into a series of tools to support the movement curriculum. Along the way we have taken an approach to making, where the value of craftsmanship is present in making specific outcomes for our clients and patients. It is our aspiration that the student will develop and contribute to the work already done and use the tools and systems on behalf of their patients and clients goals in a collaborative manner that involves both more deeply in the practice of improving function and specific activities of life.
The difference between the Structured Motion approach and other approaches is the questions that it starts with. These questions guide the development, implementation, progression, regression, and conclusion of the change effort.
The first question we start with is “What does the client/patient want in terms of an outcome?” This question comes from the value of making things. When working in the medical model, it is common to first start with the question “what is wrong that is causing the symptoms and signs?” This comes from the value of wanting to get rid of something, namely the cause of the problem. From these two very different starting points the end results will be very different.
This is why I have always appreciated the collaborative work with my medical colleagues. Much of the problem solving and elimination of disease or management of disease is in support of the work that we do, namely developing physical capacity in support of life activities that are meaningful to the patient or client. It’s worth clarifying again, the medical model is not functional restoration and the work that rehab professionals perform are not curative of disease. Its worth making the obvious explicit here, because the two have very different value structures and as a result will require different underlying structures to promote the outcomes desired. With this clarified perspective we can be to investigate the work of improving function and the involvement in life that are patients and clients desire.
Some of the ideas here are not new, for human motion has been studied and a variety of disciplines have investigated the inherent relationships in the body that produce function. However what is unique is that the approach presented to improve or restore function is not dependent upon a specific intervention technique or philosophical approach. Furthermore as the organizing principle is the desired level of function, it is not impairment centric. This is a striking difference from approaches that are prescriptive to eliminating an unwanted impairment. Have this problem, apply this technical procedure. The goal of the change efforts developed with a Structured Motion approach is not simply the elimination of loss of ROM or the return of specific muscle strength. You can get rid of all of the impairments in the human body and still not have the function that is desired. It’s worth repeating, you can correct all the problems and impairments and still not have a body with the capacity to be involved in life at a household, community, recreational or professional level.
The reason that the above is true is that human function is not a product of a lack of neuromuscular restrictions, but instead is derived from the coordination of the human form by the nervous system to produce an orchestrated support of the COG BOS relationship. How movement professionals, whether they be rehabilitation and/or performance experts organize the observations, data, conclusions, decisions and actions towards an end result is the subject matter of Structured Motion. What maybe adequate at one level of function may not be successful in supporting a higher level of complexity of movement. In this way, human function becomes a continuum with human form providing the support to orchestrating the progression and regression of the COG BOS relationship notable in functional activity.
Structure Motion is an investigation and application of clinical decision making strategy and the relationships of component parts of the decision. The investigation has been about the underlying structure of the plan of care itself, and the impact that the structures that professionals work in impact the outcomes. This approach supports the clinician to step into the plan of care for a close up of the specific motions required for a joint to perform as well as step back to see how that motion is impacting the overall function. This is supported not only by a knowledge base of human anatomy and kinesiology.
It also includes an understanding of strategic thinking and planning as used by professional artists, business, and other makers of goods and services. The role of decision making and the different ways the mind reacts to states of unknown. And an investigation of the role that the arrangement of relationships between component parts into structures produces tendency to behavior. Form and function is found in the human body and its functional product as well as the form of the plan of care and the decision making it produces.
In the upcoming installments we will examine the role that structure plays in restoring function and the component parts of the Structured Motion approach.