Tag: Movement Skills

Experimenting with the Berg – 14. Component 13

Submitted by: Jeremy Nelson PT

13.0 Standing Unsupported One  Foot in Front

The goal of this component is to be “able to place foot tandem independently and hold 30 seconds test hip abductor control as now in relative adduction”. Although not typically part of the function of life (unless your occupation is a tight rope walker) component 13 does provide useful information to assist in developing the overall plan of care. This component is evaluating the capacity of the performer to weight shift, establish new bases of support and maintain the COG in relation to the new BOS. First task is to establish an asymmetrical base of support by stepping forward. In maintaining foot position 1 foot for the other so again was looking at weight shifting in the capacity to control that weight shift with the close kinetic chain lower extremity in addition once the asymmetrical base support is established were examining control the center of gravity over narrow base of support along and diagonal pattern

As the performer demonstrates “Loses balance while stepping or standing” there exists profound inability to control static balance. If the loss of balance comes when stepping then the weight shift did not happen and gravity won the day before the performer was able to establish a single limb BOS. As discussed in the previous articles, any time the performer demonstrates such a low score, the approach would be to step down to the lower level positions and critical tasks. With a review of these supportive tasks, the areas of inadequacies can be improved towards the desired level of the critical task. Having completed the lower level task, the performer will be on a firm foundation for advancement.

Even if the performer “needs help to step but can hold 15 seconds” an examination of the supportive critical tasks are in order. As organized in the hierarchy of movement, the asymmetrical and single limb positions would be supportive to this more complicated task. An inability to weight shift to single limb to establish a new BOS could be present for a number of reasons. What at first looks like a separate test are really the prior critical tasks revisited.

Similar to component 12, time is an element in the test as well as understanding what is required to accomplish the task. It takes time to position the advancing lower extremity into the position that is desired. The scores imply that time for the step to occur is adequate or not. For example when the performer is “able to take small step independently and hold 30 seconds” the weight shift was not likely adequate and the step is a quick step as the brain rapidly attempts to reestablish a BOS before a loss of balance occurs. The time is increased by the strength and power of the stance hip. When the performer has been “able to place foot ahead independently and hold 30 seconds “ an adequate weight shift to during the single limb position has occurred resulting in the establishment of a new BOS, and a capacity to demonstrate to maintain control of COG over BOS.

Experimenting with the Berg – 4. Component 2

Submitted by: Jeremy Nelson PT

Component 2.0 – Standing Unsupported

This component is seeking to learn more about how well the patient is able to maintain the center of gravity over their base support in an elevated position. As the center of gravity rises above the base of support there is an increase in the kinetic energy. New forces are imposed on the structure of the body, and the body needs to respond to control the dynamics. So the static standing is more challenging for the neuromuscular system than being seated. In the seated position, control of the center of gravity is enhanced by a larger BOS, within the base of support that includes the pelvis, femurs and feet.

In addition were looking at the quality of the passive range of motion within the skeletal structure to attain extension as well as the extensors of the body to resist the pull of gravity. The human skeleton has a few tricks to assist with maintain full extension; however it requires adequate passive range of motion into extension and adequate length of the flexors to attain this. Thus an assessment of posture is worth adding to these observations. Knees that are unable to meet full extension and take advantage of the screw home mechanism may be caused by knee flexion contracture or hip flexion contracture. Being that the scoring is time dependent, the endurance factor also leads to a better understanding of the conditioning of LE and posture efficiencies.

This component BOS is a symmetrical stance. Within the component the sub-components allow for an opportunity to change the amount of support in order to up towards the ability to stand safely for two minutes. To score 0 you must unable to stand for 30 seconds unsupported. And to score one point there is a need for several tries to stand 30 seconds unsupported. Although not part of the scoring, the clinician may investigate within this score to see what impact single upper extremity support going from bilateral upper extremity support has on the standing balance.

There are a number of reasons why patient would not be able to stand unsupported. The most common is the position of the knees and hips remaining in a flexed position which increase the amount of mechanical strain on the system. 0° hip extension and knee extension allow for the joints and bones to support the standing. When the hips are flexed and unable to extend to neutral the internal rotation of the femur is lost. As a result the screw home mechanism in the knees is not available, thus reducing stability of the knee. This also burdens the patient as they must to do a lot more work during standing. Instead of the skeletal structure contributing to maintaining the COG above the symmetrical base of support, instead anterior chain is excessively used as this puts the COG near the posterior aspect of the BOS.

The symmetrical standing posture is not typically used in most functional activities, as the body is better positioned in an asymmetrical stance to move. With this component asymmetrical stance can be enhanced and the overall function of the patient improved.

Structured Motion Approach – 4. Performance Skills

In the previous installments, a number of introductory components of the Structured Motion approach have been described. Starting with a focus on making specific results, the client or patient is then engaged to ensure that the result being made is really what is wanted by the patient or client. As part of being an expert in the field, it is easy to decide for the patient or client what they should want. It is also important, given that these processes and actions are expressions of the value of freedom, that the patient be a collaborator in the outcome. This is an active process of collaboration in which the client or patient identifies what they want and the professional organizes around that outcome. Included in this is the freedom of the patient to not accept the intervention by the rehab professional. It is essential that the client or patient is choosing to be involved, and choosing to act on behalf of their involvement in life. If the client or patient refuses service, then further referrals to the appropriate professional can be made. It has been our experience that there are different levels of desired involvement in life. This is different than depression or a withdrawing which again would require a referral to the appropriate provider. It is this initial process of organization by the professional that will be introduced in this article.

At this point a report that presents the comparison of the desired level of function as identified by the client and the current levels of ability is generated to assist in the assessment process. Each specific activity identified will have one or more performance skills category which includes those movements that observable. These are typically what is referred as functional movements. These movements are often tested using standardized testing such as the berg test. Examples include: sitting and standing, turning in a circle, reaching for something on the floor and a host of many more functional activities. These movements become the entry point into the assessment of the person’s ability to perform the desired specific activities identified earlier. These performance skills are more than just movements on a macro scale, but are really movement strategies of the brain in orchestrating the body to manipulate the COG BOS relationship. All motion includes the controlling of the COG either statically or dynamically in an ever changing BOS.

The movement skills are further defined in terms of the COG and BOS relationship within the observable Performance skill category. For example within the category of bridging, the COG will start out in the BOS which is the length of the body as the person is resting in supine. The BOS will then change to a 3 point of both feet on the ground and the trunk as the person attains hook lying position. The COG then is dynamic as the body raises the COG above the 3 point BOS and the BOS further changes from the trunk to only the upper spine, scapulae, neck and head in contact. After attaining maximal rise, the lowering begins, requiring a different muscle contraction and level of control, until the beginning level is returned to.

This clarification of the functional movement as it relates to the desired specific activity and its related definition of COG and BOS relationship provides a framework in which the COG and BOS relationship will be present throughout the assessment, evaluation, and change effort. In this way questions regarding the impact of an intervention on body movement or posture can be compared with its result on the COG BOS relationship as it will determine the functional involvement in the desired activity.