The BOS will give rise to tendencies of movement, however in human form, it is not the BOS that is dominate, it is the COG position that determines the use of anterior or posterior chains. An example of this confusion is the use of the wall slide to promote improved sitting to standing, or squatting. Certainly this exercise seems to look like sitting to standing as the body appears to be in a squat like position. However this exercise is ineffective in promoting improved sit to stand as it does not include the critical tasks found in a hip hinge, nor does it replicate the BOS COG relationship that is critical to a successful sit to stand.
This is the reasoning behind the granularity found in the Structured Motion approach. Even as I developed it, I asked whether the form was promoting a majoring in minutiae. Was the approach creating a burden? For the purpose was to make something that supported the clinician in producing the specific outcomes desired by the client. After using it from some time it became clear that this was indeed the work to be done. It takes the time and steps that it takes to examine the relationships that lead to functional movement. The usefulness in the telescoping form that underlies the structured Motion approach is that the time spent is on the areas that are causative to the desired levels of function. As the assessment continues, there is a documentation of the observations, the clinical decision making and the needs of skilled involvement. With all elements linked together into a series of relationships, the story about the patients function and the need for change to a higher functional capacity can be entered into at any point and the reader will have a clear view of why the intervention is required.
This makes the collaborative effort between clinical staff more effective. The cause and effect relationships are presented and the underlying clinical reasoning is presented in a way that promotes the discussion between clinicians about what is being observed. As the change effort begins, a clear point of departure is established for change to be measured from. In this way, the effectiveness of the approach is demonstrated and the outcome documented.
The change effort itself has distinct phases with a hierarchically arranged workflow. These phases are related but general enough to be unburdened by a specific approach or intervention. This supports the clinician’s freedom to implement interventions that they are most effective and confident in administering with resulting increase in patient or client safety as well. The structure of the change effort also calls for frequent clarification of the current state of the critical tasks, body segments, and function at different perspectives. Again, in this way the clinician can zoom in to asses a specific joint motion and then zoom out to observe how an intervention is impacting the critical task required for a performance skill that may be assessed by a standardized tool.
Licensed assistants are more effective in this structure as well as supervising therapists are able to maintain control of the change effort without being controlling. Progresses towards critical tasks are directly linked to the interventions that are being delegated. All clinical staff involved are clear on what the outcome will look like and how to measure the current state of the patient. Specific technique is not the focus, for the clinical staff may have different approaches which will be complementary to the outcome.
At the level of the change effort, the rehabilitation specialist will be introduced to the telescoped form that guides the workflow of the treatment planning and interventions. As rehabilitation specialists we have a knowledge base of postures, ranges of motion, joint mobility and stabilities, and specific strengths of muscles to produce the desired functional motions required. Assessment of bones, joints and muscles are a major part of the work to be done. Again, the wealth of data to be collected is likely overwhelming, leading to clinical decisions based on assumptions and abstract thinking about what is likely to be there, based on diagnosis and other clinical data points. Interventions become organized around these assumptions and clinical pathways are developed that take the place of clinical decision making. There is a place for tissue healing phases and progressions; however the entry point into these phases must be supported by clinical observations, not simply assumptions. For years insurance companies and regulators have complained about interventions performed without a reasonable justification of skilled need. In a way, they are right. Interventions are a in support of a change effort. Each change effort is unique as each patient’s functional status and physical capacities are unique. What is appropriate for one patient is supported by a clear assessment of reality. If function continues to be our beginning and ending of change effort, then interventions are in support of that functional change.
However, too often, due to the lack of granularity in the record of the plan of care, those joining elements that are influenced by the intervention to produce the change in function are unexamined, unrecorded and invisible to the person asking “how did doing this, result in a change in that”.