Submitted by: Jeremy Nelson PT

6.0 Standing Unsupported with Eyes Closed.

This component of the Berg balance test references the neurological structures that provide data to the brain. Specifically it examines the sensory structures that provide information about the body’s position in time and space. The capacity of the brain to organize around this data is also implied in the results of this test. Both provide a place for further development of a plan of care as the critical tasks for the symmetrical stance and the single limb task are the outcomes that the motor system uses the data to develop.

As a quick review, the sensory system includes the afferents of the eyes, vestibular system, the proprioceptors on the joints and the touch receptors of the skin. As the eyes are closed for this test, the visual data provided by the eyes about horizon, distance, motion is not available. As a result, the vestibular system and the sensory system are providing the data for the brain to organize balance. Although it is not a specific test of the vestibular system, this test can be a jumping off point into other test such as the CTSIB. It provides evidence for further investigation of the specific elements of the sensory system when scores indicate that balance is undermined when the eyes are closed.

A couple of lines of inquiry are supported by the data from this test. The first is in regards to the information coming from the sensory system. Is this data sufficient; are there enough nerve impulses to be a point of information for the brain to organize around, without the visual information from the eyes? Degenerative conditions such as diabetic neuropathy cause the changes that may lead to a paucity of information from the base of support skin. Due to damage of the peripheral nerves, inadequate data is available for the coordination components of the brain about what is happening at the BOS. This can sometimes be an excess of information from the pain fibers early in the condition before numbness is permanent.

Without the sensory information the brain does not know if it’s a symmetrical stance, asymmetrical stance or single limb position at the base of support. Where then to place the COG? How to organize the muscle actions when this data point is unavailable or inadequate? With the eyes closed, data that was assisting the organization is not available. However if the special testing indicates the sensory system is adequate, the next question is asked.
The next inquiry is about the brains capacity to use the information to control the COG over the symmetrical BOS. The goal is to maintain static posture in a symmetrical stance. The motor and balance sections of the brain work with the two data points of the BOS and the COG. As data in the form of nerve impulses coming from the sensory centers register the brain responds by orchestrating muscles in a coordinated fashion to support the dynamic and control. Given adequate sensory data, then the changes observed maybe a question of coordination.

The change effort is focused on the learning of the nervous system of how to use what data is available to complete the critical task. The strategy is to provide the best opportunity for learning by using the phase of learning motor related tasks. When the patient scores low and “needs help to keep from falling” there is a profound loss of sensory data from the lower extremities. The most basic level of learning that is being able to perceive something. Perception is the ability to be aware of objects, qualities, or relationships through the senses. Selecting relevant cues and relating the cues to motor acts is the domain of the balance centers of the brain. Because this is limited at this level a change effort to promote learning of the nervous system to take advantage of what little sensory data exists. Tools to increase proprioception at other joints, compensatory activities to increase the size of the base of support and core strengthening to maximize the COG control are approaches to enhance the COG BOS relationship.

When a patient is “unable to keep eyes closed 3 seconds but stays safely”, the plan of care is focused on the use of imitation as a strategy. Copying an action demonstrated by the rehab professional. This is observation and replication. Guided response through the performance of another person and/or repeating performance. Only through a great deal of trial and error can the brain learn to orchestrate the movements.

At the level of “able to stand 3 seconds” and “able to stand 10 seconds with supervision” reproduction of the critical task from instruction or memory is the focus. Guidance is withdrawn and the cueing limited. The patient is provided a variety of situations and tasks in which the critical task will be utilized. Self-correction of the failing efforts is the desired outcome for the patient to be able to set up themselves in the varying physical demands they will encounter in the world. Finally, the goal of “able to stand 10 seconds safely” confirms the patient’s ability to set up the body to complete the critical tasks. Being ready for response to through mental, physical preparation is further enhanced by practicing the critical task with eyes closed.

When using a problem solving approach, this component can seem hopeless. No treatment available will restore the damaged nerves. However as educators of movement, we can use the tools and structures developed by professional educators to enhance the learning. When viewing this component within the context of the COG and BOS relationship and thinking about the critical tasks that are required in higher levels of complexity movement, the rehab professional is better positioned to consider creating new strategies to get the job done. Instead of asking what can be done to restore sensation, instead it is what can be done to complete the critical task. In fact this is a principal of successful neurological rehabilitation. To organize around the diagnosis is to try to restore damaged tissue to impact function. To organize around the critical tasks for movement, with the principles of motor learning, a higher degree of success is likely.