Tag: Desired Outcomes

Experimenting with the Berg – 13. Component 12

Submitted by: Jeremy Nelson PT

12.0 Place Alternate foot on Step or Stool While Standing Unsupported

This component examines the capacity of the patient to perform a weight shift to unload the extremity that is going to perform the step up motion. The goal of the component is to be “able to stand independently and safely and complete 8 steps in 20 seconds”. The time part of the test provides an insight into the overall coordination power that exists in the neuromuscular system. The first task is to perform the weight shift and maintain center of gravity over the base support of the foot into a single limb pattern. The more difficult task comes next, supporting of the stance limb of the stepping up of the contralateral side.

As the lower extremity flexes at the hip and knee to place the foot on the stool, the posterior moment must be countered by the stance limb with an anterior moment. The stance hip must be strong enough to support the COG and BOS relationship in the single limb position as well a counter the posterior moment.
If the performer “needs assistance to keep from falling/unable to try” then presumably the first task was not completed. Without the initial weight shift the stepping lower extremity is unable to be unweighted to perform the motion. This is likely from inadequate control of COG to perform the weight shift or an inadequate BOS in terms of poor foot posture. Reviewing the asymmetrical stance critical tasks into the single limb critical tasks will provide the desired outcomes to measure current reality against.

Again, similar to the other Berg components time is an element to investigate and record speed as function of strength, coordination and power. In order for the extremity to successfully step up there needs to be adequate time for that to happen. The time is developed through the shifting of the body weight to the extremity that is going to be in a close kinetic chain into a single limb position.
As is described in the Component 14 discussion, the single limb position has been involved in many of the movements being examined at the end of the test. With improved single limb support, the control of the step is developed. The strength and control of the extensors and abductor’s are being examined as if there is an inadequacy in either one there will not be enough time for the patient to step up without assistance.

When the performer is “able to complete > 2 steps needs minimal assist” what type of and what degree the assistance is needed is important to identify. When using the upper extremities to assist in stabilizing the COG over the BOS to complete the weight shift points to inadequate gluteal strength or posture of the hip and knee. Assistance required to step up maybe related to the poor knee mobility.

When the performer is “able to complete 4 steps without aid with supervision” and “able to stand independently and complete 8 steps in > 20 seconds” both indicate that the critical tasks are present and the body is able to produce. The difference is a matter of speed and coordination. As the speed increases the size of the weight shift begins to narrow. The larger weight shifts in the lower scores are replaced with small shifts. However this is not to indicate that the forces that the muscles produce to counter are less important. In fact the opposite is true. As the hip strength and power increases the COG is suspended over the BOS for shorter periods of time and the return to the start position. Better control is developed and the performer is able to respond to the demands of life safer and with more confidence.

Functional Outcome Tools: Timed Up & Go Test (TUG)

Timed Up & Go Test (TUG)

In the upcoming weeks the article series Functional Outcome Tools will be published with valuable information on the purpose, patient population, and extendability of the data received from the test. Please fill in the form below to submit questions you would like to have answered in the article series. By following the link below, a PDF version of the test is available.

Timed Up and Go

Functional Outcome Tools : The Tinetti

Tinetti Performance Oriented Mobility Assessment (POMA)

In the upcoming weeks the article series Functional Outcome Tools will be published with valuable information on the purpose, patient population, and extendibility of the data received from the test. Please fill in the form below to submit questions you would like to have answered in the article series. By following the link below, a PDF version of the test is available.

TinettiTool

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 – Improving Functional Movement with Rhythm and Momentum

It really has been one of those days at work, and the day is not even half over, still a few more clients to see. Paperwork is piling up, phone calls, billing, it seems like there is never enough time.
And then it happens. Something special happens with a client or patient. It’s clicking. Both focused, the movements and instructions combine into collaboration. Even poorly executed moves are quickly improved on and there is energy in the session. There is a real momentum towards the clients’ goals as the actions taken have been specific and focused. Compliments are exchanged: “Great work out, I really feel great, I didn’t think I could do it.” “Yeah, you did great, way to really go for it.” “We did great.”
Given that it was unexpected what caused the change? Wouldn’t it be great if every session went the same way?
What happened?

You found the groove.

The following series of articles is an exploration of how to develop the momentum to initiate and sustain change efforts over the time required for the change to occur. This is done through the organizing of complementary data points into relationships. Depending upon the starting point of the change effort, the needed time will be different, as each outcome is a specific occurrence, unique to its circumstances and situation. Here is an example: Same patient, same shoulder, same rotator cuff tendonitis may be present in your office. However these are two unique times on the calendar, points in time. To consider that the previous approach is all that is required to restore the shoulder to function is to miss the essential data points of current reality. This assessment of current reality in relation to the desired result is the fundamental value pairs that will be the building blocks for the architecture of the “groove” building to come.

The groove may not be tangible but you can experience it. The groove is the time when all actions support the results that are wanted. A sense of momentum, building towards a result. The actions are sometimes familiar, rout movements and recognizable approaches. Other times, invention is called for as a different unexpected, unanticipated approach produces the desired result. And like a good dance team, someone needs to lead the collaboration. The practitioner is the leader. One who has mastered the skills of using structures and strategy is well positioned to improvise on the fly while maintaining the groove is leading the collaboration with the client.
By taking two complementary but different pairs and arrange them together, a cause for change is established. In biology this is seen in the action potentials generated in nerve tissue, as the potential for change is created by the difference in charge on opposite side of a membrane. In physics this is seen with the seeking of balance between hot and cold. What is the underlying dynamic here is for a structural arrangement of different pairs to seek equilibrium. This force can be organized to produce the needed dynamic over time to sustain changes.

What about clinical decision making and the plans of care that are products of this strategic process? Do they have component parts, parts that are complementary but different? And if so can they be arranged to produce a groove towards a functional outcome? As a rehabilitation or sports performance professional you value getting results. Great news is that other fields are experts in making things, creating, producing consistently.  Read on to learn how the capacities of the arts are being applied to the restoration and improvement of human function.

Structured Motion Approach – 3. The Desired End Result

It starts with the level of function the client is seeking. Again, for those who have been part of the movement professional community, this can be an abrupt change from the typical seek and destroy mission that is organized around what problem to get rid of. Pain and loss of function will certainly be addressed; however without the context of an overall desired level of function, something specific, the change effort is likely to end when the pain or problem intensity subsides. Identifying patient’s true aspirations is done through a survey of the in regards to activities the patient or client wants to be involved in. A quick assessment of the life categories helps to identify where the focus will be, as areas that are deemed adequate can be reviewed but not assessed specifically. After the client has chosen a few of the specific activities that interest them, they are asked to self asses their current abilities by choosing similar tasks that are associated with varying levels of difficulty. These levels may be defined as a different performance skill that is required, a different energy level required of both.

This first action is asking the patient or client what really matters to them may seem trivial, a nicety, and window dressing to the real work to come. The purpose of this exercise in identifying true aspirations is to generate the momentum and interest in the work to come. Frequently in a problem solving structure in which the expert is the provider and giver of the solution, the patient or client becomes passive. It’s not their fault, as they are simply reacting to the implied expectations that it is their job to be a passive participant. By asking for what is desired, the foundation for true involvement is set. However it is not enough to know where they want to go. We also need to know where they are now. This observation and recording of where the patient status is now in relation to the desired outcome is the work to be done. It begins with the client taking the first steps.

The client then performs an assessment of their general mobility capabilities. This is done through the client being instructed to perform a series of motions in different BOS. Supine, seated, squatting, standing in a stride stance, and standing on one leg are progressively requested depending on the prior, simpler levels answers to the question. The client selects from 5-7 different descriptions of the action performed and asked to select that description that most closely describes their ability at that time. This progression is for safety as it is reasonable to conclude that a person who cannot sit unassisted is unlikely to be able to stand without significant need of assistance. In addition, it is reasonable to conclude that client with this scoring would be in danger if asked to perform a stride stance balance test or a single limb balance test. As a result those tests are only offered to those who are able to demonstrate an acceptable lower level score.

After the conclusion of the mobility test, a self-test of aerobic capacity is performed. For those with low mobility scores, the aerobic survey is presented for completion. This self-survey provides a reasonable approximation of aerobic function. Starting with this allows those with potential for unsafe movement to provide data but not be at risk. For those with higher level scores on the mobility screen, both the aerobic survey and a 6 minute walk test is performed. Both forms are presented to the user and the appropriate check boxes are made for the aerobic survey and data added to the requested text boxes. The program then calculates the scores and presents the MET levels.

After this is completed a report is presented that demonstrates the results of the mobility test and what are the percentiles for that movement pattern. Also the MET scores are presented. A separate report is presented with a clickable list of acceptable activities for the person to perform based on both their mobility scores and MET levels. This list is life area specific. This list is provided in response to the question “What can I do now, given my current functional capacity.” This offering is a direct expression of the value of involvement that our company holds as an organizing principle. Why wait to encourage involvement? Regardless of the level of capacity, many life activities can be presented as reasonable ways to get involved.

The report also presents the comparison of the desired level of function as identified by the client and the current levels of ability. The general mobility and MET level is compared to the tasks and energy requirements of the function and a recommendation regarding current ability is presented. If the general mobility and MET levels are lower than the desired levels, the change effort will include remediation of lower levels. If the current levels are greater than the desired levels then the user is exempted from those lower level activities. At this point the specific desire results can be investigated for physical capacity to perform and a change effort presented for the user to develop maximal capacity. An example of a user with higher level of current ability still requiring education on lower levels would look like the following. A user wants to be able to sit and work at the computer for extended periods of time and is currently able to pass all components of the general mobility and 6 minute walk test indicates a MET level of 10.5. The seated activity requires a MET level of 2.3 for example. The lesson presented would include supine chop lift, seated hip hinge with core integration and squat progressions all to assist in maximizing seated postural ability.

Why use these exercises…Structured Motion is about intensification of functional movements. With this approach a strong foundation of actions on behalf of the patient or clients goals are initiated. The upcoming installments will describe how the change effort progresses and the focus on creating a specific outcome.