Tag: Progressions

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.

In the Groove – 6. Creating Momentum

How does one create this type of momentum?

Creating momentum and it roles in advancing the motor learning process is also one of the least understood aspects of how to produce increased performance in a short period of time.  Rhythm can be used for motor learning within an individual lesson. This rhythm can be sustained from exercise to exercise using progressions within bases of support. The impact is a lesson of motor learning that includes adequate repetitions and multiple learning iterations of “make a mistake, learn the lesson, try it again.”

How can this momentum can sustained during the plan of care cycle over weeks and months, consisting of multiple unique appointments. Individual single session can be linked together to create sustained change over time with a technique borrowed from music composition.
We have already seen in other articles how the use of form assists in structuring of changes efforts over long periods of time. These internal relationships generate momentum. The momentum developed through organizing the internal relationships can be sustained over time by arranging the sub components in relation to the larger goals.   This strategic arrangement of goals, sub goals, current reality of those goals and actions create an internal framework of change.  Actions taken on behalf of bringing the two data points closer together create the rhythm that established the groove. Rhythm is the result of carrying that form in varying dimensions of time. Each very small dimensions of time is related to another through form, to create components that relate over longer periods of time, resulting in sustainable change efforts.

Arranging time and sound has been the life’s work of Hugo Norden who taught music composition.   Again the arts have something to teach us about how to create consistent results. From the book Form: The Silent Language, Norden describes the misconceptions students of music composition must dismiss in order to effectively design music.  He describes it as a basic misunderstanding of how the symbols of music and math have undermined the design process.  The concept of music produce a misunderstanding of the relationships of notes, and the mechanics of relating and arranging musical notes together into a comprehensive creation that communicates the desired expression.

He describes how most children are taught in their music lesson to “count time” from bar line to bar line, thus:

Notes 1234

As a result the music composition student, as they are learning to design music naturally follows the same sequencing.   In this way, the first note written is followed by the sequence above.  In this way it was the preceding note that the following note is based on.  However, this burdens the making of the composition as each segment of music becomes isolated and lacks continuity and integrity with the rest of the composition. One stanza is isolated from the overall movement.

Norden further drives the point home as he writes,
“This is a gross misconception which many students never outgrow!” He completes his thoughts by describing the frustration that is common for the musical composer using this approach.  Momentum is non existent in the music and the act of creating the music.

We have observed something similar in students of physical therapy, athletic training and in practicing clinicians. In the process of creating results that impact movement, the relationships between components of the plan of care can become categorized. That is they are isolated into silos such that a treatment plan to produce improved sitting to stand function becomes generalized. The internal relationships are lost and as a consequence momentum is undermined. The result is a sense of starting over each time the patient or client arrives for their appointment.  The choices made today does not relate to the overall goals of the program.

Progression towards the desired result is lost. Squat pattern training does more than just improve a sit to stand transfer. A squat pattern creates the needed strength to master the increasing complexity of a stride stance balance and wt shifting in asymmetrical stance. And without an adequate foundation in the squat pattern, single limb pattern is very difficult to progress.  In this way an opportunity to increase the clients desired involvement in life is missed and the impact of the change effort is temporary as the underlying structure of the approach is to provide only temporary change.

 

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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.