Tag: Functional Movement

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 – 5. Rhythm

Rhythm is the result of organizing the relating parts in a way to generate energy. In change efforts in which a result is created, there may be many sub results that are necessary and must precede the overall result. Returning to the example of making a cake we see that sequence does indeed matter.   The dry product is mixed with the wet product to form the cake batter.  The sequencing of putting the contents together is just as important as the quality of the contents itself.  When seeking to create a treatment that produces accelerated motor learning the parts of the treatment need to be organized to generate the different rhythms desired.

In the rehab world this looks like sequencing the treatment planning towards movement related goals. Each functional movement is composed of many sub component movements. Shoulder flexion includes flexion at the glenohumeral joint as well as external rotation and abduction. Miss one or more of the movements and the shoulder will not flex. Flexion is primary, abduction supports flexion, and external rotation supports all the above. To miss this relationship results in shoulder exercises that unspecific and lack an impact on functional improvement. The best joint mob, the perfect execution of stretch, the perfectly timed trigger point release will not have an impact if performed in the wrong sequence. Yes, sequence does matter.

Changing perspectives and backing up to see how the shoulder impacts and is impacted by the rest of the body, we can use the progressing scale of center of gravity and base of support pairs to increase or decrease the functional demands on the shoulder.  We can also, knowing that the position of the thoracic spine will be determinant on how the scapula will move, change our perspective to examine the hierarchically arranged parts.  The shoulder will also behave differently due to the change in the behavior of the thoracic spine in sitting or stride positions, or standing on one leg.

How do we as movement specialists organize the actions of the change effort? It is a question with a variety of different stylistic answers depending on your field of study, the time frame of your practice, etc. However, if it is human movement that is the subject, there are constants. The styles of practice are a spectrum, from a free flowing impromptu jazz style, to a rigid classical approach. Whatever your technique of choice, you can learn to design a program that has an underlying groove to it. In music, the groove, refers to the underlying bass line that supports the free styling, harmonizing, and melody of the other instruments. It’s palpable in funk, Rand B, rock, and other forms of blues derived music. It is also present in classical music. In jazz, the groove, is what allows the individual musicians to solo off into the outer regions and return home without losing their way.  No matter what they play it seems to work.

The groove is also obvious when it is absent. No groove means no life, no soul of the music, and without the groove no matter what the musician creates it will seem flat.  Without a well organized, scalable, integrated treatment approach you will find that impact made on your patients function is at most temporary.  To use rhythm to generate in conjunction with the groove is to be well positioned to create what is uniquely required for level of involvement your patient or client would like in their life.

Structured Motion Approach – 7. Professional Collaboration

The BOS will give rise to tendencies of movement, however in human form, it is not the BOS that is dominate, it is the COG position that determines the use of anterior or posterior chains. An example of this confusion is the use of the wall slide to promote improved sitting to standing, or squatting. Certainly this exercise seems to look like sitting to standing as the body appears to be in a squat like position. However this exercise is ineffective in promoting improved sit to stand as it does not include the Continue reading Structured Motion Approach – 7. Professional Collaboration

Structured Motion Approach – 5. COG BOS and Imposed Demands

We ended the previous installment with an introduction of the star of the show, the COG and BOS relationship. The article also introduced the notion that this relationship was determinant, in other words it would be the most influential on function. This article continues to develop the point and sets the stage for the change efforts in upcoming installments.

Each of the different COG BOS relationships is imposing a new demand on the neuromuscular system as the kinetic energy is increased as the COG moves away from the BOS and the need for the production of internal stability is increased as the BOS changes to a less stable form. Within each of these snap shots in time of the COGBOS relationship, there are Continue reading Structured Motion Approach – 5. COG BOS and Imposed Demands

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.

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