Tag: Education

Experimenting with the Berg – 8. Component 6

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.

Movement Professional as Educator: 3. The Educator

We have already explored the mind of the learner and the deviations that can happen when a framework for assessment and orientation is not present. What about the instructor without a curriculum to provide guidance? What do professional educators know about their own learning, their own self-assessment that is valuable to the movement professional?

In this case it is the mind of the clinician we will observe. When a clinician enters the room to collaborate with a patient or client, the clinician brings their assumptions, worldviews, values and other mental constructs. Often it is the clinical model that is the star of the show, as the clinician employs the techniques and skills of their trade in gathering information to provide clear diagnoses. With diagnoses in hand, the prescription is set and the problem solving can begin until the problem is eliminated. This problem solving framework is how much of the education system has trained practicing clinicians.

Contrast that with the patient taking center stage. What does the patient want in terms of a result? From these conversations, a specific outcome or results can be identified and the resources, decisions, skills and focus is organized around this specific result. At this point, a new framework is required to work in, that will bring about the desired level of function, to support the strategic choices required over a period of time to bring about the desired changes. Process now becomes focused, in support of a specific result. Given that the end result is now the organizing principle; a process that does not support the end result will be modified or even abandoned as convention makes way for invention. What is driving this effort? The end result.

Here is the thing. You can’t problem solve your way to the desired level of function. Why? You can solve all of your patient’s problems and alleviate all of their impairments, but they still will not be able to function if the motor learning has not occurred to employ the new ranges of motion, the new strength on behalf of the level of function. They still will not be able to produce the motions that are required if they have not learned the specific motions to support the specific result.

With a curriculum that provides depth and breadth, with internal relationships that provide a place to go during the learning process, the educator is focused on the end result. With the tools available for assessment, clarity about where the educator is in relation to where they need to be in terms of grasp of knowledge, application of skills, analysis of cause and effect, decision making and designing programs can be clearly determined. Through collaboration with professional educators, movement professionals can improve the educating skills and aptitudes that improve their clients and patients involvement in life. With a robust curriculum and lesson strategies, the impact the choices and actions made to improve movement will be long lasting and continuing to make an impact long after the learning is done.

Movement Professional as Educator: 2. The Students Mind

To have a deeper insight into how apparently disparate parts of information impact each other is one of the hallmarks of real learning. Relationship seeking, cause and effect driven structures as they are our minds can use this information to take action on desired results and make the outcomes that did not previously exist. And yes, old dogs can learn new tricks. However learning something new can be fear producing in many students. A student by definition is beginning at a place of not knowing. And as was discussed in the first article of the series, the mind does not care for this state. In fact it will make things up to alleviate the discomfort of not knowing. Good students typically have developed a tolerance to this state of the unknown. A competent educator knows how to use the potential energy available to support the change effort that the student is presenting.

The task of the educator is to create a new structure for the mind to explore cause and effect. An underlying structure of a clear outcome and an adequate understanding on the student’s current knowledge and capacity levels in relationships to the outcome produces a clear path to learning. Structure is causal. It has tendencies and the use of different structures in the plan of care will result in specific outcomes. It is the educators’ choices that will determine the structure to be used and the forces in play generated by the structure.
In this way, the educator is an architect, building the structure for the mind to step into, to begin exploring. The new structure, like a jungle gym provides the mind with the chance to begin to see new possibilities, learn new skills and shift its perspectives. The curriculum is more than just a collection of facts and knowledge to be presented. A well-developed curriculum is three dimensional, with internal relationships. It is hierarchical in that there is complexity at that top that is supported by lower levels of complexity and difficulty. It explicitly and implicitly demonstrates cause and effect. With this insight the learner is able to become the causative factor in their lives, as they seek to make choices to reorganize the materials on hand towards more of what is desired and take actions that are measurable in terms of their impact.

What differentiates competent educators with the newbies and wannabies? Is it the grasp of the knowledge they were presenting? Maybe a background rich with experiences to highlight and explain the content presented in the real wold? All helpful, but what really is the key the skill to assess the state of learning of the student. It takes the educator to have not only a clear understanding of the curriculum and its component parts but also how to assess the state of learning of the student in relation to the behaviors, skills, and aptitudes within the curriculum. With these two complimentary data points of where the student wants to go in terms of the curriculum and where they are now, a real dynamic is produced to activate the change effort. The quality of the measurement tools used by the educator will impact the clarity of current reality. Standardized screening and assessments produces reproducible and credible data that supports the change effort to come.
Again, the movement professional will see similarities when teaching lessons of movement. Whatever philosophy the curriculum is rooted in, whether yoga, Pilates, biomechanics, or insert your favorite approaches here, it must include an effective assessment component. Otherwise the learning loses steam when things get tough. Focus is lost and the mind does what the mind does. In this case find something else easier to try and the collaborative effort is lost as the learner becomes unavailable for learning.

Through the collaborative effort the student has the opportunity to examine the sequencing and role that there clinical decision making made on the outcome with the instructor. It is the student’s role to do the heavy lifting in thinking it through. This is sometimes an insurmountable task and always a task that is challenging. When it is too much it is the educator’s role to know how to reorganize the learning in a way that the learner will develop the knowledge, skill, aptitude necessary to move to the next step. Sometimes it requires stepping down and re-consolidating to form a more firm foundation to take the next step up. As movement educators we need to know how to regress the movement lesson into a lower level of complexity and find the area that is in need of remediation. This is done through the ability to produce smaller components and granularity in your movement curriculum.

Here is the good news. In education, much of the designing of learning as change efforts has been researched and understood. There are a number of different approaches, such as Blooms Taxonomy and many others, which organize actions and behaviors into hierarchies. In much the same way, the movement curriculum presented in the Structured Motion courses is organized to present a clear outcome and how it relates to higher more difficult levels of movement. As stated earlier, curriculum is not of much use unless the student and instructor activate it through the assessment of the student’s current level of learning. Through using both data points, the learner is well positioned to gain the skills and knowledge to be involved in their life.

Movement Professional as Educator: 1. The Job to Be Done

Education requires more than the ability to retain and recite facts and figures.  The days of the stern task master, focused on route memory are well behind us.  Educators have many roles, many tasks to perform on behalf of learning.  Movement professionals in rehabilitation and sports performance are educators. What can the fields of academic learning teach to the movement professionals about creating motor learning? Years of educating has produced clarity about the work to be done and who is accountable for what in the student-instructor relationship. Clarity on the roles and skills required for both will produce the dynamic required for needed learning and for the desired changes on behalf of the learner. For educators, it is important to know also what the student is accountable to produce.

It is not the job of the educator to take the action for the student. And it is certainly not the role to do the learning for the student. Clearly, it is not the job to motivate the student. Nor is it the job to organize the student’s choices for them. There are a number of jobs that are not the movement professionals, and these are a few of them. These are the realm of the student.
The work to be done as an educator is to organize the environment to support the learning of the student. Making assessments about the state of learning, and making choices about presentation of information, all are critical to developing a successful change effort.

The successful movement educator has not only a grasp of the facts and figures, the knowledge base, but also how to arrange that knowledge into focused movement choices. A Physical Therapist for example is not responsible to do the exercises, learn the movements, and choose to move differently for the patient. It is the role of the PT to setup the plan of care and subsequent treatment lessons in a way that promotes not only cognitive learning, but motor learning. And just as professional educators can attest to, more than just a grasp of knowledge is required for real learning to occur.
This can be news to the professional who has viewed him or herself as solely a fixer, a mechanic, a changer of muscles and joints. More likely the movement professional sees the need but was not educated as an educator and as a result is not aware of the curriculum building process, the lesson development approach and the impact that structuring learning has on long term acquisition of skill. A well-developed curriculum provides the framework that I described above. Providing footholds and hand holds for exploration of knowledge and development of skills.

Educators are also are performers, as a presenters of information. To make it interesting for the audience of learners it is important to engage with the learner, to focus the attention. Learners that are clear about how the information will impact their lives and how the information, skill, aptitude is on behalf of something that matters to them are interested. Presentation that includes the learner, asking them to interact with them as the information is presented; asking for their feedback promotes higher levels of the brain. Content that is more contextual for them based on my understanding of their backgrounds and experiences brings in prior learning that can build upon.
The same is true when working with a patient or client. Promoting the clear understanding of how this movement skill impacts their life and how improving their movement choices will provide them more involvement in life as they desire.

What really draws the learner in is to have the cause and effect explained, to have a deeper insight into how apparently disparate parts of information impact each other. Our minds are relationship seeking, cause and effect driven structures. Given the opportunity, a mind will gnaw on a problem, seek to understand what happened and keep chewing away on a problem like a dog chewing on a bone until the mind is satisfied that it understands. Another way to look at this inherent ability of the mind to seek understanding is the behavior associated with a state of not knowing. With enough plausibility the mind will create false, fictitious explanations to release the tension associated with not knowing. Although not true the mind will hold on to that explanation, again like the dog protecting its bone. Ever try to take a dogs bone away…probably was the last time you tried. However, create a new structure for the mind to explore cause and effect and begin to let go of old ideas as it reaches out to new hand holds on the structures and real learning can take place.

In the next article the students mind and tendencies when learning are discussed. It takes more than just understanding what is to be taught to the student, to produce a successful outcome. The values supporting this approach is a desire to see the learner involved in their life as they choose, and to have the capacity to perform at a level that matters to them. In this way the educator impacts more than just the learner, but through extension, the learners’ impact on the community.