Tag: Intervention

Experimenting with the Berg – 11. Component 9

Submitted by: Jeremy Nelson PT

9.0 Pick Up Object From Floor From a Standing Position

Although 9th on the list of tests in the Berg, when examining this component for complexity it is near the top of difficulty. The goal of this component is to be “able to pick up slipper safely and easily”. How the performer completes this goal can be divided into a number of possible strategies; one that is a symmetrical stance involving a full hip hinge or squat, or an asymmetrical stance involving a modified split squat and finally as a single limb golfers lift. As a result, this component allows us to not only learn something about the current control the center of gravity in a changing base of support but also lets us know the preference for movement.

Strategies that the performer demonstrates in order to accomplish the task identifies which BOS they are most comfortable. The split squat pattern in which the person squats down to pick up the object from near the feet provides information about the asymmetrical BOS. The golfers lift in which the performer goes into a single limb to pick up the object implies a higher degree of neuromuscular development. This will be useful in organizing the change effort to come as well as knowing where on the hierarchies of critical tasks to begin and progress.

When the performer is “unable to try/needs assist to keep from losing balance or falling” there exists a profound inadequate control of the COG. This shouldn’t be a surprise at this point in the testing as the prior test components would have provided evidence the level of complexity demonstrated in this component would be unattainable. As discussed in the prior articles, this score indicates that there is work to be done in the prior supporting levels. Basic critical tasks are absent and the body segments utilized to complete these critical tasks are inadequate in more than one way.

When the performer is “Unable to pick up and needs supervision while trying” it is worth noting which base of support strategy was employed. A change effort to improve the performance in this component would most likely start in the base of support that is presented. Symmetrical base of support using the hip hinge would return to the prior functional reach critical tasks. An asymmetrical base of support could include the split squat as an entry point. And if the performer presents the golfers lift, the stance phase of ambulation would be a good entry point to consider. A problem solving approach, without considering how something is moving and seeing this simply as lack of lower extremity strength will be unlikely to succeed. There is simply to many data points that are related to consider one solution as adequate.

As the performer demonstrates “unable to pick up but reaches 2-5 cm(1-2 inches) from slipper and keeps balance independently” an adequate control of the COG over the preferred BOS can be implied. At least to the point of near the ground. The question here is whether the inability to reach the ground is due to mobility, inadequate flexibility of the body segment, or inadequate stability to attain the control required reaching the ground and return. The human brain is very good at knowing its limits and not getting caught into a position it can’t get out of. What at first looks like inadequate flexibility of tissue to attain a position could also be neurological based muscle guarding as the edges of coordinated movement are reached.

To investigate the questions, the first place to start is to return to the critical tasks of each base of support and investigate what level of flexibility and mobility exist. The seated hip hinge with reaching to the ground demonstrates adequate flexibility if all body segments perform as expected. As the base of support narrows and the complexity of the movement increases, the investigation turns to dynamic stability. The golfers lift is a complex movement that more likely indicates control of the COG to complete the task then flexibility. Further control would be demonstrated by “able to pick up slipper but needs supervision”.

By including the BOS as a data point when observing this component, further progressions or regressions can be organized. As the performer attains the goal in a symmetrical stance, move to the asymmetrical stance to complete the picking up of the object. Having attained the goal in the asymmetrical BOS, the single limb BOS is available. In this way the patient is provided a wide range of demands to learn from, resulting is greater preparation for the demands of the real world.

Experimenting with the Berg – 7 Part 2 – Component 5

Submitted by: Jeremy Nelson PT

5.0 Transfers – Part 2

Examining the scoring matrix for this component a wide level of capacity is documented. At the lowest levels the patient “needs two people to assist or supervise to be safe” when moving from one surface to the other. This can have a number of causes and would include inadequate control of the COG to promote any level of stability. Although a higher level of function when the patient “needs one person to assist” there continues to be a lack of COG control. As discussed earlier, these scores do not provide an explanation for why what is occurring, is actually occurring. Any intervention to move towards the next level of function would include an explanation of the body segments contribution to the critical tasks of the movement, in this case inadequate.

To be “able to transfer with verbal cuing and/or supervision” the patient now demonstrates a capacity to control the COG to initiate a weight shift, although continues to require verbal instruction on how to sequence and complete each critical task. The difference between a squat transfer and a standing pivot transfer is the ability to shift the body weight to unweight one of the lower extremities to change position. Transferring requires the center of gravity be maneuvered within the base of support the patient needs to be able to shift their body weight throughout that base of support. The control of the COG to produce the weight shift likely includes critical tasks already performed in the seated and sits to stand motions. Having completed those elements, the patient would be better positioned to orchestrate the complex movements in order to change and establish a new BOS.

Why would a patient be “able to transfer safely definite need of hands”? The upper extremities are extension of the COG control. With the upper extremities supporting weight or providing more information to the brain through touch, the nervous system can better organize the weight shifting and positioning of the COG relative to the changing BOS. Again here the rehab professional is well positioned to describe the use of the upper extremities, whether for support and control of the trunk or simply for touch. Each level of upper extremity supports provides data to support the interventions planned and to document changes as a result of the intervention.

When the patient demonstrates being “able to transfer safely with minor use of hands”, the Berg component is satisfied. However the movement professional may not be as through collaboration with the patient it is learned that the transfers required by the patient to participate in life in a way that matters to the patient are not as simple as moving from one chair to the next. In life, there are varying surface heights, hand positions, motions to be made in addition to the one previously described. As the demands change, the scoring matrix can still be employed as behaviors seen and documented. And having had developed a clear record of what interventions were causative in restoring the capacity of the body to produce the critical task movements to give rise to the functional movement, the movement professional can review their notes and be well positioned to develop progressions on behalf of the patients desired level of function.

Experimenting with the Berg – 5. Component 3

Submitted by: Jeremy Nelson PT

Component 3.0 Sitting with Back Unsupported But Feet Supported

In the seated position, the center of gravity is closer to the base of support. The base of support is also wider than what we saw in the unsupported symmetrical standing of the previous element. As a result, it is a less complex position to maintain and work in and has a lower kinetic energy. It could then seem that this component, being easier would require less attention then more demanding postures.

This is not true, and in fact sitting capacity will be important information when working on higher levels of function. The chestnut that you must first stand before you can sit makes sense. And how one sits will influence the capacity to stand as was discussed in the first component. Although not part of the test scoring, the clinician may investigate the capacity to anterior weight shift and explore the patient’s capacity to control dynamic motion. The seated position can be an entry point into improving squat transitions and standing activity.

Within the Berg, this component time is also being measured in time. This data point is often interpreted as level of strength and endurance in the extensors must musculature. More specifically it is a measure of the efficiency of maintaining the COG over the BOS in this position. As was described in the unsupported standing, a postural assessment is helpful to examine the passive range of motions and muscle lengths to attain this position. Most important is the pelvic positioning. This will have a dominant influence on the spinal posture and further positions the COG behind the BOS when in a posterior tilt. LE posturing into excess adduction will decrease the control of the COG over the BOS and instead lead to posterior rotation moment that leads to the patient using a forward head posture strategy. In essence the patient may be trying to pull herself forward with the anterior chain resulting in poor efficiencies, likely leading to fatigue and hyperactivity of pecs, iliospoas, adductors, kyphosis and poor diaphragmatic excursion. What may at first be a lack of extensors control is more likely excess activation of the anterior chain with reciprocal inhibition of the posterior chain in sitting.

A principal in using structured motion is to always have a place to go. When the client is unable to complete a certain activity in a position, step one level down within the BOS key, or into a new BOS. For this example the difficulty is going from sitting to standing. We discussed this squat pattern based movement before. Before we began working on the critical tasks needed to accomplish the goal of standing up, the supporting critical tasks within sitting had to be completed. Within this context the choice of intervention would be to enhance the patient’s ability to complete the critical task. Within a problem solving structure the approach would be to work on leg strength to promote better sit to stand.

The critical task is a derivative of the two components of COG and BOS. Each part must do its part to support the change in COG within the changing BOS. Consider the following scenario as an exploration of therapeutic exercise as an intensification of the critical task. Establishing the base of support is the first place to start in the seated position. The seated position BOS includes the lower extremities and pelvis. Begin by positioning the feet shoulder width apart and knees and into a flexed position at approximately hundred degrees of flexion and the ankles at neutral to 5° dorsiflexion. Hip abduction to roughly 35° promotes the pelvis rotated to neutral to weight bearing on the ischial tuberosities.

A possible cause of a patient needing moderate or maximal assist is that the knees are too close together. This limits the anterior weight shift capacity as they bend forward the femur stops the anterior rotation of the pelvis. As a result the lumbar spine flexion occurs and this actually positions the core into an area of flexion instead of an area neutral extension which is the body position required to attain control of the COG. In addition it positions a center of gravity behind the base of support so it’s very important that the knees are apart from each other and that the person can spill forward in that open space between the knees. Teaching the hip hinge using the physio ball initiates the core stability that supports the hip joint do the movement. Without the core stability established lumbar spine flexion occurs and causing extension of the hip joint in the closed chain.

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

What is the Purpose of Intervention? – 2. Tuning the Body

Consider the analogy of human motion as similar to music made from a guitar. Music is the product, the result of the individual components of the guitar working together. A guitar must be tuned, as it is this tuning that establishes the relationships and hierarchies of musical notes available to the performer. Notes that are required for the music may not be available on a guitar that is out of tune. This puts real mechanical strain on the performer and guitar. A guitar that is out of tune will burden the performer as they search for awkward positions to find the needed note to support the performance. The guitar cannot readily adapt and will likely experience some break down over time as the same strings are played over and over again and other strings are left untouched as they cannot support the music being played. The performer will find strain and bad habits produced as the guitar is not an efficient instrument.

However tune the instrument and all notes become available and easy to locate to the trained musician. Music with higher levels of complexity are attainable with this tuned instrument. In the human body, this change is seen during interventions for increasing mobility and stability. There is the mechanical change, and there is also the critical neurological change if the new available ROM or position is to be utilized by the nervous system. As the human body has greater coordination and consolidation of basic movement patters, higher levels of complex movement are available. Change when performed within the context of the hierarchical arrangement of the movements available in the body will result in long term capacity and on-going renewal of the body as it responds to the forces by building increasing strength and capacity.

Interventions are more successful in this structure. Using the movement curriculum, an inadequate performance on a contributing body segment can be seen as a remediation opportunity. Performance has been inadequate and after an assessment of the underlying causes of the inadequacies, a re-teaching occurs, providing valuable motor learning. This is critical as it is changes in the nervous system that are being corrected as well as at the muscle and joint level. Without the context, the unsupported movement patterns that have been “learned” by the nervous system will continue to be produced with only correction of the joint.
One of the dominant notions has been that of the intervention as a tool of correction to restore function. The notion is that full function is just on the other side of the wall that is limiting the function capacity of the patient. Break through and eliminate the impairment and function will be restored.

Spontaneous return of function after the “releasing” of impairment
Vs.
Availability of body segments to support the hierarchy of critical tasks that support the COG and BOS relationship.

Here is a thought experiment to consider for the movement professional. Both of the above statements refer to increasing mobility of a segment or joint. A successful intervention will make a motion available to the brain. How is the brain to use this available motion? If the brain is seeking a functional outcome the COG BOS relationship will be dominant. As a result that motion will be employed on behalf of the COG BOS relationship.

More mobility at a joint is not always the desired result, if that new motion does not support the other component levels. An example is ankle dorsiflexion for ambulation of a patient with neurologic weakness. Dorsiflexion is part of the critical task of the tibial anterior translation during the loading response into stance phase. In the well organized extremity, adequate dorsiflexion promotes the translation which is controlled via quadriceps and gluteal control of the lower extremity. In the case of a weakened lower extremity, it may be the best course of action to allow the ankle mobility to become less than fully mobile, promoting improved control of the anterior tibial translation. How much is a judgement call by the rehabilitation professional as it is essential to understand the role of dorsiflexion on the foots capacity to form an adequate BOS. To release the gastroc soleus to full mobility would undermine the function. Seen within the context of the functional result desired and the critical tasks that support the COG BOS relationship, the clinician is better positioned to intervene on behalf of improved function.

To make an intervention from a place of clarity of cause and effect and a clear observation without the assumptions of what should occur is a firm footing for producing the change effort desired by the patient.

What Is the Purpose of the Intervention? – 1. The Role of Structures

Rehab professionals  speak of treatment interventions as corrective actions. Picture a body segment that is out of position, not moving right, burdened by a problem of stiffness, weakness, or something that is stopping it from working correctly. This then is the stimulus for the actions that will take place, to change the bent to straight, or the straight to bent. With this accomplished the change effort ends and the collaboration between patient and therapist is completed.  Too often however the functional gains are not sustained.  The initial change is followed by a decrease in corrective actions.  Only after the complaint gets to intolerable levels again does the patient/client take action.

What is going on here is the problem solving structure that is being used results in less action as the intensity of the problem decreases. The structural approach and strategic organizing of the plan of care will impact how the interventions are employed. A problem solving structure to get rid of the problem is not a bad choice. However it may be an inadequate structure if the level of function that is desired is not at the current level of the patient.If this is the case, then a different, more robust structure to support many changes over time is needed.

It is helpful to understand the anatomic structure of a body segment, as this is the underlying cause of the function of that segment. It is also helpful to understand how the underlying structure of the plan of care impacts how the change effort will proceed. For the rehab and performance specialist focused on changing function, knowledge of how that body segment will move in different kinetic chains locally is important to understand what outcome is desired. How this movement contributes to the support of critical tasks that are occurring in support of functional movement puts the local movement on the segment into context of the whole body activity. This requires a framework to provide perspective and context of how the body segment contributes to function.

Corrections are done within the context of the body positions required to perform the critical task. The correction is either a mobilization to promote increased motion or stabilizing to promote control. This correction is dependent upon the hierarchically ranked critical tasks. At one point, the knee maybe needing greater mobility, as in the critical task of establishing the base for the sit to stand movement. At another time the knee needs greater stability to accept the body weight shift in asymmetrical stance. It is worth pointing out that it is the influence of the hip that will determine how the knee behaves. To simply focus on interventions that are local to a joint without the context of how that joint is influenced by other joints and its impact in turn is to miss the point. Within a framework that identifies these internal relationships, choices regarding intervention can be more focused.

The change effort also takes place on multiple levels of the hierarchy of function and the underlying body structure.  Interventions are different at the highest level of function.  This level includes the patient/client having knowledge and being apply knowledge about the functional movements.  An example of this is the patient being able to self assess function, and identify changes away from functional limits that increase risk of injury.  A patient with knowledge of the connection between sit to stand to sit completion and overall fall risk as it relates to choosing appropriate equipment for safety is well positioned to maintain safe functional movement.   As function is supported by critical tasks and the body postures required to accomplish these tasks, interventions become more specific and focused.  This hierarchical intervention allows for a granularity of understanding by the clinician, promoting the specific application of an intervention.

This is the difference between technicians and clinicians. Technicians employ interventions or perform data collection from standardized tests. Their focus is on process, on following the directions. A competent technician is invaluable to the clinician, as the clinician can trust the data before and after the intervention is accurate.   The role of the clinician is to interpret that data, look for relationships, seek to understand cause and effect and make choices about what is to be done next. Clarification of current reality is critical for the clinician. The testing maybe reproduced confirming the results. Or if something different occurs, the collaborative conversation can begin about what is being seen. Perhaps an intervention is not required after all.

Interventions that are borne of choices that take account of the internal relationships of movement and the hierarchies that exist in human movement are well positioned to support needed motor learning. The intervention makes available to the nervous system the body positions and body motions so that the brain can utilize these when organizing movement. When we mobilize a joint, it is only of benefit if it supports a critical task. When we perform soft tissue mobilization to lengthen a muscle, it is only valuable if the new motion promotes the completion of the critical task, and the antagonist of the muscle is better able to perform in the context of a critical task. With context as part of the decision making process, a successful change effort can occur.

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