Tag: Balance

Experimenting with the Berg – 7 Part 2 – Component 5

Submitted by: Jeremy Nelson PT

5.0 Transfers – Part 2

Examining the scoring matrix for this component a wide level of capacity is documented. At the lowest levels the patient “needs two people to assist or supervise to be safe” when moving from one surface to the other. This can have a number of causes and would include inadequate control of the COG to promote any level of stability. Although a higher level of function when the patient “needs one person to assist” there continues to be a lack of COG control. As discussed earlier, these scores do not provide an explanation for why what is occurring, is actually occurring. Any intervention to move towards the next level of function would include an explanation of the body segments contribution to the critical tasks of the movement, in this case inadequate.

To be “able to transfer with verbal cuing and/or supervision” the patient now demonstrates a capacity to control the COG to initiate a weight shift, although continues to require verbal instruction on how to sequence and complete each critical task. The difference between a squat transfer and a standing pivot transfer is the ability to shift the body weight to unweight one of the lower extremities to change position. Transferring requires the center of gravity be maneuvered within the base of support the patient needs to be able to shift their body weight throughout that base of support. The control of the COG to produce the weight shift likely includes critical tasks already performed in the seated and sits to stand motions. Having completed those elements, the patient would be better positioned to orchestrate the complex movements in order to change and establish a new BOS.

Why would a patient be “able to transfer safely definite need of hands”? The upper extremities are extension of the COG control. With the upper extremities supporting weight or providing more information to the brain through touch, the nervous system can better organize the weight shifting and positioning of the COG relative to the changing BOS. Again here the rehab professional is well positioned to describe the use of the upper extremities, whether for support and control of the trunk or simply for touch. Each level of upper extremity supports provides data to support the interventions planned and to document changes as a result of the intervention.

When the patient demonstrates being “able to transfer safely with minor use of hands”, the Berg component is satisfied. However the movement professional may not be as through collaboration with the patient it is learned that the transfers required by the patient to participate in life in a way that matters to the patient are not as simple as moving from one chair to the next. In life, there are varying surface heights, hand positions, motions to be made in addition to the one previously described. As the demands change, the scoring matrix can still be employed as behaviors seen and documented. And having had developed a clear record of what interventions were causative in restoring the capacity of the body to produce the critical task movements to give rise to the functional movement, the movement professional can review their notes and be well positioned to develop progressions on behalf of the patients desired level of function.

Experimenting with the Berg – 7 Part 1 – Component 5

Submitted by: Jeremy Nelson PT

5.0 transfers – Part 1

Functional outcome tools like the Berg provide a useful framework for documenting change over time. However answering the question of why that changed happened, and what were the causes of the changes observed requires the unique skills of the movement professional. The functional outcome tools provide a framework for identifying progress over time, as each scoring matrix demonstrates improvement towards a desired level of function. However those data points require further translation making explicit the relationships that give rise to the behavior being observed. Only after this reconstituting of the goal into the component parts can these elements become data points to organize a change effort around.

In the rehabilitation market today, the question “Is the intervention provided the cause of the change observed?” is the so called $50,000 question. Did the change occur as it would have any way, such as the natural progression through the inflammatory phase? Or was the change a result of another intervention, such as the elimination of pain through medication? Functional tools such as the Berg assist in identifying the desired levels of change however more is to be done by the rehabilitation specialist. The role of the rehabilitation specialist is to take that observable and measurable task and then examine and evaluate its constitute relationships. These relationships not only occur between person and the environment but include relationships between body segments and within those segments at the level of individual joints and muscles.

If the medication was the cause of the improvement, then what about the contributing body segments? Is there an acceptable level of organization to produce movement that is nondestructive? This question, motivated by the value of prevention, is a valuable use of the rehabilitation professional’s time. Are the body segments coordinated enough to provide safe movement in other typically environmental demands? Again the rehab professional has the unique tools to comment on the movement of a patient that has had the initial problem of pain reduced to provide improved function.

Consider the fifth component of the Berg, the Transfer. Transfers are basic staple of the work that is done by rehabilitation professionals. It seems so basic and simple, and yet when evaluating and working to improve transferring, the complexity can often be overwhelming. Up and to this point, the berg test has examined the COG in motion or maintained in a position relative to a static BOS. True, the sit to stand and stand to sit does include a change in BOS, however the transfer includes the change of BOS at the level of the extremities as well.

Observing a transfer from one chair to the other both the COG and BOS control is on display, the neuromuscular system ability to control the center of gravity while also organizing a changing base of support . Within a base of support that may include upper extremity support and given that it is a pivot transfer and is not necessarily stand pivot transfer what we may be observing is a use of the upper extremities to compensate for an inability of the core musculature to control the center of gravity. The rehab professional is uniquely qualified to comment on how the transfer is taking place, describing quality of movement. Just because a patient demonstrates movement consistent with a a defined score, it may not be in way that is safe over the long run.

Experimenting with the Berg – 6- Component 4

Submitted by: Jeremy Nelson PT

4.0 Standing to Sitting.

Much can be learned about the contributing body segments when observing the stand to sit motion. The body is doing more than just reversing gears from sitting to standing. Now the neuromuscular system is dealing with the acceleration of the COG caused by gravity. This is much different from the acceleration needed to overcome inertia when raising the COG above the BOS.

As a result, a different type of muscle contraction and a new level of coordination are required. The eccentric movement places a greater demand on the extensors muscles. Therefore we get to learn more about the patient’s ability to control the deceleration. Eccentric muscle contractions involve the selective deactivation of motor units and the maximization of other motor units. In this situation there is little room for error and any weakness that exists in the neuromuscular system will be magnified. Poor posture and body segments that are not contributing to the COG BOS relationship will further burden the system resulting in a loss of balance.

Consider the contribution of the thoracic spine. Commonly the thoracic spine presents in varying degrees of kyphosis. The thoracic spine although a firm structure, does contribute mobility to allow for the lumbar spine to remain stable and the cervico-thoracic junction to create a stable foundation for the highly mobile cervical spine. In addition, the mobility of the thoracic spine produces a guiding force contributing to the dynamic stability of the scapulae to support the highly mobile gleno humeral joint. Excess kyphosis of the thoracic spine impacts many of the critical tasks required to complete a smooth lowering of the COG.

First, the center of gravity must be well positioned in the symmetrical base of support. With thoracic kyphosis, immediately the body is compensating for the forward head position, resulting in a weight shift posteriorly. With this force moment already established the typical motion is to begin the stand to sit motion with a flexion of the knees, as the body attempts to keep the center of gravity within the BOS. As the knees continue to flex, the BOS begins to change as the heels lift. As a result the performer begins to lose balance anteriorly and will further compensate by a posterior weight shift to balance the feet. Overwhelmed by the force demands, the quadriceps begins to fatigue, or knees begin to hurt. A hard landing occurs with the falling backwards as the posterior moment accelerates.

The key is to change the thoracic spines capacity to support the required position to control the COG over the BOS. Manual techniques as well as therapeutic exercises can be employed to restore the thoracic spine posture. A complete extension of the thorax and pectorals is often required to return the thoracic spine and reduce or eliminate the forward head posture. Returning the cervical spine and head to their natural position also assists the vestibular system in outputting accurate data to the brain about position in time and space. With posture improved, the change effort is not completed as the goal is to promote the control of and not just capacity to.

The key here is to initiate from the hips using the hip hinge in the standing symmetrical position. The hip hinge was present in the sitting to stand motion and helped explained the different scores for the component. So is the case for the standing to sitting. The scoring includes a range from “needs assist to sit” to “sits safely with minimal use of hands”. Along the way the berg identifies the use of hands and the back of the knees to control the descent as well as the degree of control present. The use of hands and knees is a compensatory strategy to use the extremities to control the position of the COG in the BOS. Without maintaining the COG in the BOS it will be impossible to complete the lowering . This can only be done by first hip hinging to complete the tasks.

There is another way to use the hips and knees to promote the hip hinge. Cueing the patient to reach and touch their knees initiates the hip hinge. How the movement professional progresses the plan of care to improve the standing to sit movement will determine how well this motion is available to the nervous system when performing higher level tasks that will be seen in the proceeding Berg components. The inclusion of different paces of movement, supportive equipment and cueing to produce the optimal learning environment for the nervous system to learn how to control the eccentric motions will be critical in improving the patients’ involvement in life.

Experimenting with the Berg – 5. Component 3

Submitted by: Jeremy Nelson PT

Component 3.0 Sitting with Back Unsupported But Feet Supported

In the seated position, the center of gravity is closer to the base of support. The base of support is also wider than what we saw in the unsupported symmetrical standing of the previous element. As a result, it is a less complex position to maintain and work in and has a lower kinetic energy. It could then seem that this component, being easier would require less attention then more demanding postures.

This is not true, and in fact sitting capacity will be important information when working on higher levels of function. The chestnut that you must first stand before you can sit makes sense. And how one sits will influence the capacity to stand as was discussed in the first component. Although not part of the test scoring, the clinician may investigate the capacity to anterior weight shift and explore the patient’s capacity to control dynamic motion. The seated position can be an entry point into improving squat transitions and standing activity.

Within the Berg, this component time is also being measured in time. This data point is often interpreted as level of strength and endurance in the extensors must musculature. More specifically it is a measure of the efficiency of maintaining the COG over the BOS in this position. As was described in the unsupported standing, a postural assessment is helpful to examine the passive range of motions and muscle lengths to attain this position. Most important is the pelvic positioning. This will have a dominant influence on the spinal posture and further positions the COG behind the BOS when in a posterior tilt. LE posturing into excess adduction will decrease the control of the COG over the BOS and instead lead to posterior rotation moment that leads to the patient using a forward head posture strategy. In essence the patient may be trying to pull herself forward with the anterior chain resulting in poor efficiencies, likely leading to fatigue and hyperactivity of pecs, iliospoas, adductors, kyphosis and poor diaphragmatic excursion. What may at first be a lack of extensors control is more likely excess activation of the anterior chain with reciprocal inhibition of the posterior chain in sitting.

A principal in using structured motion is to always have a place to go. When the client is unable to complete a certain activity in a position, step one level down within the BOS key, or into a new BOS. For this example the difficulty is going from sitting to standing. We discussed this squat pattern based movement before. Before we began working on the critical tasks needed to accomplish the goal of standing up, the supporting critical tasks within sitting had to be completed. Within this context the choice of intervention would be to enhance the patient’s ability to complete the critical task. Within a problem solving structure the approach would be to work on leg strength to promote better sit to stand.

The critical task is a derivative of the two components of COG and BOS. Each part must do its part to support the change in COG within the changing BOS. Consider the following scenario as an exploration of therapeutic exercise as an intensification of the critical task. Establishing the base of support is the first place to start in the seated position. The seated position BOS includes the lower extremities and pelvis. Begin by positioning the feet shoulder width apart and knees and into a flexed position at approximately hundred degrees of flexion and the ankles at neutral to 5° dorsiflexion. Hip abduction to roughly 35° promotes the pelvis rotated to neutral to weight bearing on the ischial tuberosities.

A possible cause of a patient needing moderate or maximal assist is that the knees are too close together. This limits the anterior weight shift capacity as they bend forward the femur stops the anterior rotation of the pelvis. As a result the lumbar spine flexion occurs and this actually positions the core into an area of flexion instead of an area neutral extension which is the body position required to attain control of the COG. In addition it positions a center of gravity behind the base of support so it’s very important that the knees are apart from each other and that the person can spill forward in that open space between the knees. Teaching the hip hinge using the physio ball initiates the core stability that supports the hip joint do the movement. Without the core stability established lumbar spine flexion occurs and causing extension of the hip joint in the closed chain.

Experimenting with the Berg – 4. Component 2

Submitted by: Jeremy Nelson PT

Component 2.0 – Standing Unsupported

This component is seeking to learn more about how well the patient is able to maintain the center of gravity over their base support in an elevated position. As the center of gravity rises above the base of support there is an increase in the kinetic energy. New forces are imposed on the structure of the body, and the body needs to respond to control the dynamics. So the static standing is more challenging for the neuromuscular system than being seated. In the seated position, control of the center of gravity is enhanced by a larger BOS, within the base of support that includes the pelvis, femurs and feet.

In addition were looking at the quality of the passive range of motion within the skeletal structure to attain extension as well as the extensors of the body to resist the pull of gravity. The human skeleton has a few tricks to assist with maintain full extension; however it requires adequate passive range of motion into extension and adequate length of the flexors to attain this. Thus an assessment of posture is worth adding to these observations. Knees that are unable to meet full extension and take advantage of the screw home mechanism may be caused by knee flexion contracture or hip flexion contracture. Being that the scoring is time dependent, the endurance factor also leads to a better understanding of the conditioning of LE and posture efficiencies.

This component BOS is a symmetrical stance. Within the component the sub-components allow for an opportunity to change the amount of support in order to up towards the ability to stand safely for two minutes. To score 0 you must unable to stand for 30 seconds unsupported. And to score one point there is a need for several tries to stand 30 seconds unsupported. Although not part of the scoring, the clinician may investigate within this score to see what impact single upper extremity support going from bilateral upper extremity support has on the standing balance.

There are a number of reasons why patient would not be able to stand unsupported. The most common is the position of the knees and hips remaining in a flexed position which increase the amount of mechanical strain on the system. 0° hip extension and knee extension allow for the joints and bones to support the standing. When the hips are flexed and unable to extend to neutral the internal rotation of the femur is lost. As a result the screw home mechanism in the knees is not available, thus reducing stability of the knee. This also burdens the patient as they must to do a lot more work during standing. Instead of the skeletal structure contributing to maintaining the COG above the symmetrical base of support, instead anterior chain is excessively used as this puts the COG near the posterior aspect of the BOS.

The symmetrical standing posture is not typically used in most functional activities, as the body is better positioned in an asymmetrical stance to move. With this component asymmetrical stance can be enhanced and the overall function of the patient improved.

Experimenting with the Berg – 3. Component one

Submitted by: Jeremy Nelson PT

Component One- Sitting to Standing

Another way to say that a person cannot stand up on their own is that they can successfully, repetitively fall back into the chair. Although this is not desirable we can ask the question, how do they do this? To find the answer consider the COG BOS relationship as primary. Everything else such as strength, mobility, and coordination is secondary, that is in support the dominant task of organizing the COG and BOS relationship. Beginning with this primary components, each can be investigated and evaluated as being supported by their component parts.

A person, who requires their hands to stand up needing several tries for success, typically has the center of gravity posterior to the base of support. This is evidenced by the observation of when they go to stand up they fall backwards, not forwards. The center of gravity is not supported by the base and as a result the person is falling back into the chair repetitively. It is not a function of leg strength, although that may be contributory. Instead it is a fault of position.

To investigate this claim, try to stand without first shifting your body weight forward between your separated feet. It will seem impossible, because it is. What must first occur is an anterior weight shift of the COG into the BOS. This is called the critical task. What strategy is employed to create this critical task is the choice of the clinician.

As the article series progresses each component of the Berg will also identify one of the critical task. Understanding the critical tasks for each movement supports the establishment of goals and sub goals. An interesting experiment is to examine how the scoring of each component can be the beginning consideration for each set of goals. Here is a deeper look at this first component of the Berg.

To score 0 on this component the patient needs moderate or maximal assist to stand. Whatever you call it, moderate or max, it’s not functional, and instead points to inadequate foundation for movement at both the COG and BOS levels. Here is a person who cannot generate the force required to counter the forces that are experienced during the sitting process, let alone the forces part of transitioning to standing. Typical reasons for why someone would need this type of assistance from going from sitting to standing posture are varied; however they all share the same elements of the two data points that produce structural tension.

The center of gravity/base of support relationship is the starting point when working with someone who has a moderate to maximal assist for sitting to standing. The goal will be to improve the body’s capacity to establish and maintain this relationship, and change the positions of each element to support functional movement. Bringing this relationship together decreases the amount of strain on the neuromuscular system. By simply rearranging those elemental parts, rapid changes in function can occur.

It’s not uncommon after using some of the establishing the base support techniques as well as teaching a hip hinge can a person go from a moderate to Max or Max to requiring a minimal to contact guard assist with utilization of bilateral upper extremities. Not in weeks, but in a few sessions. So the lesson here is to learn how to do anterior weight shift where the center of gravity is controlled and moved anterior within the base support moving from the posterior aspect of the day space support towards anterior aspect while maintaining control. In this way, the patient will complete the sitting to standing component and be well positioned to complete the more difficult tasks ahead.

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