Tag: Critical tasks

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

In the Groove – 3. The Role of Form

If we step back from just watching the creator and observe the patterns the creator uses we will see distinct repetitions of sequences. One action follows another, resulting in a defined outcome. However unlike a distinct process where the same action always follows the same step, these directed actions are open. This is called a form. Forms are generalized areas that are in relationships to each other. An example is a tax form. The areas are generalized, income, expense, deductions etc, but the amounts, and types of content may be vastly different from person to person, or the same person from year to year. The result is each section provides the relevant result through a series of actions to produce a sub-element of the overall result.

In music there is a form that produces momentum, unlike the tax form which produces for most vertigo and nausea. The Sonata form is a specific form. Each form has component parts that are in relationship to each other and when combined, provide a place holder for a variety of notes to be organized. In this way, the music is always different as it contains different notes, but those notes are held in relationship to each other in a way to sustain the development of momentum.

It is the use of form as an organizational approach that promotes the ongoing production of results, and also allows those results to be different or the same. In producing improved function, the form is to first identify the what level of involvement and what specific activities the client or patient would desire. Then their current abilities are assessed in relation to that master goal. The process of assessment and evaluation involves multiple iterations of the telescoping form. In this way, the parts maintain a consistent relationship with each other and support components can be evaluated in context of the overall master goal. Functional tasks that are present in a desired activities are then assessed as well as the demands each task requires for the center of gravity and base of support relationship that is primary to the human form. For here, further assessment of the desired position, strength, flexibility, coordination to produce the requirements of the functional task are once again related to the current reality.

In this way, multiple iterations of the same form are used and organized into a telescoping structure to produce a powerful underlying structure to support an ongoing change effort. In the case where the initial approach has not made a change in current reality that was desired, the clinician can return to each component part, re-assessing and re-evaluating. In this way the momentum that was produced can still be utilized to turn around the change effort. It is easier to turn a car around that is moving then to try to turn a car that is not moving even when the car is going the wrong way.

During this revisiting of the actions and steps taken, the clinician will be evaluating the required specific critical tasks, weight shifts, muscle contractions that all support the functional outcome desired. The current ability to perform these motions are assessed in relation to the end result and specific. Relevant actions are generated that are understood as necessary to impact the specific part at the local level of joint mobility, arthrokinematics, osteokinematics and how that will impact the overall behavior of the body in terms of control of the center of gravity and base of support relationship.

In change efforts in which a result is created, these many sub results are necessary and must precede the overall result. With the use of the telescoping form, these sub results maintain their relationship to the overall end result. In making a cake, the dry product is mixed with the wet product to form the cake batter. The quality of the cake is dependent upon the many steps that happen during the dry and wet product mixing. Different proportions, ingredients, time, skill of the baker, decisions, etc, mix together to yield the resulting cake. With mastery of treatment plan design and clinical decision making your collaborations with patients and clients will be just as sweet.

Structured Motion Approach – 6. Critical Tasks

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 – 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.

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.

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.

Simplicity out of Complexity

Submitted by: Jeremy Nelson MPT

I recently collaborated with a patient on improving their mobility and function. They had a history of general aches and pains and the normal age related changes in the body that you would expect. The patient had seen a number of different therapists and trainers that were engaged to help him be able to walk better. What was provided was a number of separate exercises with the purpose of restoring flexibility and strength of the different extremities and his core. He did these and saw little change in his ability to perform on uneven surfaces.
I had an opportunity to review with the patient there previous programs and recognized the approaches as focusing on restoring and improving strength and flexibility. Not a bad approach, however there were a few critical tasks absent. By adding in a few changes to the previous program and combining many of the separate exercises into complex motions, the patients neuromuscular system was provided a new challenge and opportunity for consolidation of learning that would support the outcome the patient wanted.
As a result I found myself again pondering the relationships of functional movement and our body’s capacity to change postures, develop motion and change shapes depending on the circumstances. It is the complexity that exists in function and the simultaneous simplicity of form that gives rise to this complexity that fascinates me. It’s the gift that keeps on giving.
The fact of the matter is you can have extended knees and hips, strong and flexible but still not be able to walk with confidence over a variety of surfaces? Although important parts it is the unseen elements of human motion that are determinant in the success or failure of the brain to orchestrate movement. In this case it was the humble weight shift that is the key to the successful control of the body, maintaining balance over many types of surfaces. It happened to be the critical task that was missing in the approach to turn strength into function.
Our lives have a number of dimensions in them, and we interact with those dimensions through the activities that we participate in. It is this level of involvement that we as humans seek. And we seek to have a variety of involvement whether it be raising a family, performing a job, seeking entertainment, and participating in community or family events. It’s the unseen changing of positions of the COG to establish new bases of support and then repeating the shifting of position hundreds to thousands of times in day that we call function.
Each one of these activities includes different physical and mental demands. These demands are observable and measurable. Walking to an event can be observed and further analyzed into the gait cycle components. This analysis helps to more clearly understand what is happening in terms of the two key data points, COG and BOS. If fact, the brain acting like the conductor and composer of a musical score, directs the muscles, joints, bones to take on specific postures and positions at the correct time to support new postures and positions. The sequences are in support in the COG and BOS relationship, the fundamental relationship that provides the control for the force produced by the chemical reactions of nerves and muscles.
As the COG and BOS change position and shape, a new demand is imposed on the body and the neuromuscular system reacts by producing postures and movements to control the COG over the changing BOS. If the system is not flexible enough or strong enough or coordinated enough to produce the needed change in the COGBOS relationship, then compensatory patterns may by utilized. Although successful in the short term, these compensatory patterns often impose demands on tissues and joints that are not structured in a way to guide or absorb. As a result, tissues change, often with long term degeneration. Contrasted with a structure that guides the forces, the tissues would be enhanced and stimulated to grow to develop more capacity.
What makes the difference between a need for a compensatory movement or not is the capacity for the structure to complete the critical task necessary during that phase of the COG and BOS. When the structure of the body lacks the necessary flexibility or strength to control the dynamic relationship of COG and BOS, the brain will call upon available components to manipulate the COG and BOS relationship. As in any relationship, manipulation over time will lead to degradation of the relationship. In this case, component parts that are being asked to perform in a manner that the shape of the joint and arrangement of muscles are not structured to attenuate the forces at play will lead to break down of the bony and soft tissues over time. With an eye on the critical tasks, treatment and conditioning approaches can incorporate the essential elements in function, to support the client or patients capacity to be involved in life, as they desire.

Start with the Hip

Submitted by: Jeremy Nelson MPT

Mobility of the hip is primary. If you’re looking for a place to start with your assessment of a patient or client, we recommend starting with the hip joint. For the mobility of the hip joint will support the stability of the lumbar spine and the stability required in the knee for critical tasks of weight shifting. With increased stability of the core, the COG can be more easily controlled as the BOS imposes demands and requires static control or dynamic control of the COG. A mobile hip also assists in positioning the COG and assists the knee to lock down, increasing its stability as it prepares to accept the body weight shift.

So when a critical task is assessed, the anatomic segment and its relative posture and movement is investigated to see if indeed the body has the capacity to complete the critical task. As critical tasks, as the name implies, are essential. The body will seek to complete the action through compensatory movements in other adjacent segments.

Mobility of the body segment position pair is examined by testing the PROM to assess the soft tissue and joint integrity and length. Within the workflow of Structured Motion this examination supports upcoming decisions. If the length is inadequate in an antagonist muscle that restricts the required body position posture or motion, then the antagonist will be treated. It is important to consider the reciprocal nature of the neuromuscular system. This may further enhance the next phase of stability, as the antagonist is improved so too is the neurologic balance providing increased capacity of the agonist to produce the required stability.

The stability assessment is not only the brute force capacity of the muscle, but the nervous system current state to employ that force in a coordinated manner over time throughout the ROM. Again, returning to the critical task as the guiding force. Given the adequate mobility of the hip, do the muscles perform in a way to produce the required body position and movement to support the task? Or is a deviation observed? These deviations are at the segment level, and will cause a reaction in other segment movement as the brain seeks to complete the task to support the COG BOS position to attain the specific performance skill.

The stability assessment provides the evidence for the selection of the available therapeutic exercises. Each exercise should be an intensification of the critical task found within the functional movement. The stability assessment will identify if there is a need for group of muscles to be coordinated towards a tri-planar motion, and to what degree each muscle is acting in a concentric, eccentric or isometric manner. Again if the goal is to improve function, then those component parts of the function need to be trained in a way that reproduces the needed force production.

Returning to the hip. A hip that has adequate flexibility and strength will be able to support all of the functional movements available. Without it, attempts to improve posture, movement and balance in other areas of the body will be frustrated, and will likely return to its original state