Tag: Performance Skills

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.

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.