Submitted by: Jeremy Nelson PT
7.0 Standing Unsupported with Feet Together
This component is challenging the body’s ability to increase the control of the center of gravity given that the base support has now narrowed. As the base of support is narrowed that increases the strain on the core musculature particularly those of the hip. The goal of this component is to be “able to place feet together independently and stand 1 minute safely”. In addition to the static control tasks of maintaining the position, there is required weight shifting within the component itself to attain the test position. This includes a lateral weight shift and step of the non-stance limb towards midline on the frontal plane. This is the first peek at the capacity of the body to perform the single limb pattern and its associated critical tasks. Specifically the hip abductors are tested to control the adduction moment produced by the lateral weight shift in the frontal plane.
When the patient “needs help to attain position and unable to hold for 15 seconds” there exists limited core stability and inability to control the weight shifting required to change the BOS to the narrow position. “Needs help to attain position but able to stand 15 seconds feet together” is also a comment on the capacity to lateral weight shift. The first place to observe is the position of the hip joint. Is there a positive Trendelenburg sign indicating abductor weakness? If so, what is causing the weakness? From a problem solving perspective the approach would be to begin abduction strengthening using an open kinetic chain to isolate the gluteus medius. As the gluteus medius performs abduction it must be the offending element, and requires correction through strengthening. With enough repetition the goal would be to build the strength of the abductor to counter the adductor moment.
However within the context of the critical tasks that support increasing complexity of the COG BOS relationship, the first step would be to step down to the sit to stand to sit critical tasks. Do the hip adductors have adequate length to complete the sit to stand? Does the hip abductors have adequate strength to control the ascending and descending of the COG? What about the core strength during the anterior weight shift? By stepping down a level to examine the completeness of the critical tasks, the foundation of movement is verified. If there are abhorrent movements as this level, they will need to be completed first before the direct approach is attempted. Within the context of the hierarchies of movements, the direct approach would seek to be consistent with the critical task demands. In this case, the lateral weight shift is preceded by hip abduction and extension and internal rotation in the closed kinetic chain. At no time does this task require an open kinetic chain.
“Able to place feet together independently but unable to hold for 30 seconds” and “able to place feet together independently and stand 1 minute with supervision” verifies that a weight shift has taken place in order for the narrowing of the BOS. This may look like small, quick steps towards midline as the body weight is supported by the stance LE for only short periods of time. This pattern is evidence that the current capacity is inadequate when compared with the goal of maintaining standing for extended periods. Further examination of contributing body segments is also completed to determine the readiness to support the increasing complexity of movement during upcoming Berg components.
A final note on the importance of understanding the critical tasks within a functional movement as data points to organize the change effort. This test component could be observed to be a test of balance capacity in a narrow symmetrical BOS. If this was the case, with a low score, the place to go would be to organize around the BOS and challenge the body to hold this position. Perturbations could be included to challenge the cores ability to maintain the COG over the BOS. Different surfaces would be added to impart on the body forces that it must learn to deal with. A focus on increasing lower extremity strength could also be included.
However without a solid support of the lower level critical tasks the body segments will produce compensatory movements. Repetition of the compensations produced while the body is being “trained” to handle these forces produces learning for the nervous system. As a result, instead of the desired flexible nervous system that has mastered the coordination of muscles to produce critical tasks, the available movements are limited circumstance. In addition, without completion of the critical tasks of the performance skills of symmetrical stance and single limb positions, the nervous system will have a more difficult time in completing the tasks that are upcoming.