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.