Approaches to Therapeutic Exercise and Activity for Neurological and Developmental Conditions (Bobath and Brunnstrom Approaches) PT 154: Therapeutic Exercise

Approaches to Therapeutic Exercise and Activity for

Neurological and Developmental Conditions

(Bobath and Brunnstrom Approaches)

Approaches to Therapeutic Exercise and Activity for

Neurological and Developmental Conditions

(Bobath and Brunnstrom Approaches)

PT 154: Therapeutic Exercise III

Ms. Mary Grace M. Jordan, PTRP

23 November 2009

PT 154: Therapeutic Exercise III

Ms. Mary Grace M. Jordan, PTRP

23 November 2009

Learning Objectives…Learning Objectives…

At the end of the lecture, the students should be able to:

• Discuss the theoretical basis of the neurodevelopmental approaches

• Discuss the concepts and principles underlying the Bobath approach

• Discuss the concepts and principles underlying the Brunnstrom approach

At the end of the lecture, the students should be able to:

• Discuss the theoretical basis of the neurodevelopmental approaches

• Discuss the concepts and principles underlying the Bobath approach

• Discuss the concepts and principles underlying the Brunnstrom approach

Sensorimotor ApproachesSensorimotor Approaches

• Bobath approach

• Brunnstrom’s movement therapy

• Rood approach

• Proprioceptive neuromuscular facilitation

• Bobath approach

• Brunnstrom’s movement therapy

• Rood approach

• Proprioceptive neuromuscular facilitation

Theoretical basis…Theoretical basis…

• Neurodevelopmental model

• Reflex theory

• Hierarchical theory

• Systems approach

• Neurodevelopmental model

• Reflex theory

• Hierarchical theory

• Systems approach

Neurodevelopmental ModelNeurodevelopmental Model

• motor control and its production refers to two systems of output: the open loop (voluntary control ) and the closed loop (postural control) mechanisms

• motor control and its production refers to two systems of output: the open loop (voluntary control ) and the closed loop (postural control) mechanisms

(Keshner, , 1981)

Open-loop system…Open-loop system…

• commands sequences of movement that are centrally stored in the nervous system and that serve the functions of mobility in the production of isolated joint and limb motions

• commands sequences of movement that are centrally stored in the nervous system and that serve the functions of mobility in the production of isolated joint and limb motions

(Keshner, , 1981)

Closed-loop system…Closed-loop system…

• Dependent upon afferent feedback for the elicitation of its automatic movements that serve as the principle motility or stability of the organism

• prerequisite for the development of normal movement behaviors

• arise from patterns of coordination

• Dependent upon afferent feedback for the elicitation of its automatic movements that serve as the principle motility or stability of the organism

• prerequisite for the development of normal movement behaviors

• arise from patterns of coordination

Reflex TheoryReflex Theory

• The basic unit of motor control are reflexes– Reflexes purposeful movement– Damage to the CNS results to re-emergence of

and inability to control the reflexes

• The basic unit of motor control are reflexes– Reflexes purposeful movement– Damage to the CNS results to re-emergence of

and inability to control the reflexes

Hierarchical TheoryHierarchical Theory

• Motor control is hierarchically arranged– CNS structures involved with movement can be

grouped into HIGHER, MIDDLE, and LOWER levels

– Higher centers regulate and control the middle and lower centers

– Damage to the CNS results to disruption of the normal coordinated function of these levels

• Motor control is hierarchically arranged– CNS structures involved with movement can be

grouped into HIGHER, MIDDLE, and LOWER levels

– Higher centers regulate and control the middle and lower centers

– Damage to the CNS results to disruption of the normal coordinated function of these levels

Systems approachSystems approach

• suggests that the CNS does not operate in a strictly descending manner

• no higher levels with which to control the operation of the lower levels

• there is a mutable relationship between the various levels so that each level will alternate between command and subordinate roles in relation to the other levels.

• suggests that the CNS does not operate in a strictly descending manner

• no higher levels with which to control the operation of the lower levels

• there is a mutable relationship between the various levels so that each level will alternate between command and subordinate roles in relation to the other levels.

(Keshner, , 1981)

Bobath ApproachBobath Approach

Concepts and PrinciplesConcepts and Principles

History…History…

• Developed by Dr. Karel Bobath, a neuropsychiatrist, and Mrs. Berta Bobath, a physical therapist

• 1943 – while working with children with cerebral palsy

• Developed by Dr. Karel Bobath, a neuropsychiatrist, and Mrs. Berta Bobath, a physical therapist

• 1943 – while working with children with cerebral palsy

Original theoretical framework…Original theoretical framework…

• Based on the works of Jackson, Sherrington, and Magnus who described nervous system as

HIERARCHICAL in nature

• Model Higher brain centers exerted control over

lower-level centers Eg. The cerebral cortex control supercedes that

of the brainstem

• Based on the works of Jackson, Sherrington, and Magnus who described nervous system as

HIERARCHICAL in nature

• Model Higher brain centers exerted control over

lower-level centers Eg. The cerebral cortex control supercedes that

of the brainstem

Original theoretical framework…Original theoretical framework…

• Hypothesis A neurologic insult will lead to a release of

the lower-level centers from higher-level center inhibitory control, resulting in stereotypical postures, primitive movement patterns and predominant reflex activity

• Hypothesis A neurologic insult will lead to a release of

the lower-level centers from higher-level center inhibitory control, resulting in stereotypical postures, primitive movement patterns and predominant reflex activity

Adult hemiplegia..Adult hemiplegia..

• Treatment approach was later on expanded to include the rehabilitation of adults with motor problems, particularly CVA

• Main problem: the abnormal coordination of movement patterns combined with abnormal postural tonus (Bernstein, 1967)

• Secondary problem: muscle strength and muscle activity

• Treatment approach was later on expanded to include the rehabilitation of adults with motor problems, particularly CVA

• Main problem: the abnormal coordination of movement patterns combined with abnormal postural tonus (Bernstein, 1967)

• Secondary problem: muscle strength and muscle activity

Bobath concept…Bobath concept…

• Is a living concept, it is not static It has undergone changes in its

theoretical base to accommodate developments in the fields of neurophysiology, biomechanics, and typical development

• Holistic approach It involves the whole patient, his

sensory, perceptual and adaptive behaviour, and motor problems

• Is a living concept, it is not static It has undergone changes in its

theoretical base to accommodate developments in the fields of neurophysiology, biomechanics, and typical development

• Holistic approach It involves the whole patient, his

sensory, perceptual and adaptive behaviour, and motor problems

Traditional ViewTraditional View• Principles of treatment

– Normalize muscle tone– Inhibit primitive reflexes– Facilitate normal postural reactions– Treatment should be developmental

• Techniques– Handling– Weight bearing over the affected limb– Utilize positions that allow use of the

affected limbs– Avoidance of sensory input that affect

muscle tone

• Principles of treatment– Normalize muscle tone– Inhibit primitive reflexes– Facilitate normal postural reactions– Treatment should be developmental

• Techniques– Handling– Weight bearing over the affected limb– Utilize positions that allow use of the

affected limbs– Avoidance of sensory input that affect

muscle tone

Previously…Previously…

• The control of movement was thought to be dependent on the normal postural reflex mechanism E.g. utilizing righting reactions and

equilibrium reactions in association with normal postural tone

• The control of movement was thought to be dependent on the normal postural reflex mechanism E.g. utilizing righting reactions and

equilibrium reactions in association with normal postural tone

Reconstruction of theNDT approach

Reconstruction of theNDT approach

PremisePremise• Different parts of the CNS influence one

another

• Nervous system is capable of initiating, anticipating, and controlling movements– feedforward and feedback mechanisms

• CNS has the ability to shape and/or renew itself in response to practiced activities: neuroplasticity

• Different parts of the CNS influence one another

• Nervous system is capable of initiating, anticipating, and controlling movements– feedforward and feedback mechanisms

• CNS has the ability to shape and/or renew itself in response to practiced activities: neuroplasticity

Evidence on neuroplasticityEvidence on neuroplasticity

(Fisher, BE and Sullivan, KJ, 2001)• Neuroplasticity can occur on the lesioned side

of the cerebral cortex following CVA when provided appropriate practice in using involved side

• Rehabilitation strategies should promote recovery rather than compensation

• Techniques should incorporate the following:– Active participation in motor skill learning– Specific skills training and strengthening directed

to the involved limbs– Intense, task-specific practice that optimizes the

sensorimotor experience

(Fisher, BE and Sullivan, KJ, 2001)• Neuroplasticity can occur on the lesioned side

of the cerebral cortex following CVA when provided appropriate practice in using involved side

• Rehabilitation strategies should promote recovery rather than compensation

• Techniques should incorporate the following:– Active participation in motor skill learning– Specific skills training and strengthening directed

to the involved limbs– Intense, task-specific practice that optimizes the

sensorimotor experience

Basic premises…Basic premises…

• Sensations of movements are learned, not movements per se

• Basic postural and movement patterns are learned that are later elaborated on to become functional skills

• Sensations of movements are learned, not movements per se

• Basic postural and movement patterns are learned that are later elaborated on to become functional skills

Problems in the adult patient with stroke

Problems in the adult patient with stroke

• Abnormal tone

• Loss of postural control

• Abnormal coordination

• Abnormal functional performance

• Abnormal tone

• Loss of postural control

• Abnormal coordination

• Abnormal functional performance

Goals…Goals…

• Decrease the influence of spasticity and abnormal coordination

• Improve control of the involved trunk, arm and leg

• Retain normal, functional patterns of movement in the adult stroke patient

• Decrease the influence of spasticity and abnormal coordination

• Improve control of the involved trunk, arm and leg

• Retain normal, functional patterns of movement in the adult stroke patient

Principles of treatment:Adult hemiplegia


• Treatment should avoid movements and activities that increase muscle tone or produce abnormal reflex patterns in the involved side

• Treatment should be directed toward the development of normal patterns of posture and movement (movement patterns are not based on the developmental sequence but on patterns important for function)

• Treatment should avoid movements and activities that increase muscle tone or produce abnormal reflex patterns in the involved side

• Treatment should be directed toward the development of normal patterns of posture and movement (movement patterns are not based on the developmental sequence but on patterns important for function)



• The hemiplegic side should be incorporated into all treatment activities to reestablish symmetry and increased functional use

• Treatment should produce a change in the quality of movement and functional performance of the involved side

• The hemiplegic side should be incorporated into all treatment activities to reestablish symmetry and increased functional use

• Treatment should produce a change in the quality of movement and functional performance of the involved side



• Individualize functional outcomes• Emphasize motor control• Increase active use of the involved side• Provide practice to improve motor

performance that lead to motor learning• Teach 24-hour management to increase

retention and carryover• Use an interdisciplinary approach to

intervention

• Individualize functional outcomes• Emphasize motor control• Increase active use of the involved side• Provide practice to improve motor

performance that lead to motor learning• Teach 24-hour management to increase

retention and carryover• Use an interdisciplinary approach to

intervention

Stages of hemiplegia and the Bobath Approach


• Initial Flaccid Stage tx focus on positioning and movement in

bed to avoid the typical postural patterns of hemiplegia

• Stage of Spasticity tx is a continuation of the previous stage

with the goal of breaking down the total patterns by developing control of the intermediate joints

• Initial Flaccid Stage tx focus on positioning and movement in

bed to avoid the typical postural patterns of hemiplegia

• Stage of Spasticity tx is a continuation of the previous stage

with the goal of breaking down the total patterns by developing control of the intermediate joints



• Stage of Relative Recovery tx aims at improving the quality of gait

and the use of the affected hand

• Stage of Relative Recovery tx aims at improving the quality of gait

and the use of the affected hand

Principles of treatment: children with cerebral palsy


• Treat the child as a whole

• Basis for intervention is normal movement and their interrelationships

• Treatment incorporates facilitation and inhibition using key points of control abnormal tone is always inhibited normal responses, once elicited, are always

repeated

• Treat the child as a whole

• Basis for intervention is normal movement and their interrelationships

• Treatment incorporates facilitation and inhibition using key points of control abnormal tone is always inhibited normal responses, once elicited, are always

repeated

What are key points of control (KPC)?

What are key points of control (KPC)?

• Parts of the body where the therapist can most effectively control and change patterns of posture and movement in other body parts– Proximal: spine, sternum, shoulder/scapula,

pelvis/hip– Distal: jaw, elbow, wrist, knee, base of the

thumb, ankle, big toe– Head may be a proximal or distal KPC

• use KPC that allow full pattern to be broken during handling

• Parts of the body where the therapist can most effectively control and change patterns of posture and movement in other body parts– Proximal: spine, sternum, shoulder/scapula,

pelvis/hip– Distal: jaw, elbow, wrist, knee, base of the

thumb, ankle, big toe– Head may be a proximal or distal KPC

• use KPC that allow full pattern to be broken during handling

Facilitation-InhibitionFacilitation-Inhibition

• Facilitation is a mean by which movement is made easy,

made possible, and made necessary

• Inhibition involves decreasing the use of pathological

movements and the effects of tonal dysfunctions on movement

• Facilitation and inhibition may be used simultaneouly and may be applied throughout the session

• Facilitation is a mean by which movement is made easy,

made possible, and made necessary

• Inhibition involves decreasing the use of pathological

movements and the effects of tonal dysfunctions on movement

• Facilitation and inhibition may be used simultaneouly and may be applied throughout the session

What is handling?What is handling?Manner of controlling the patient through

tone influencing patternsManner of controlling the patient through

tone influencing patterns

• Normal patterns of activity used to modify abnormal patterns of posture and movemento Total TIPs: whole body is controlled in a

reversal of the abnormal patterno Partial TIPs: some body parts remain

free to move• TIPs are utilized via KPCs

Law of ShuntingLaw of Shunting

• “ at any moment during the movement or a postural change, the CNS mirrors or reflects faithfully, the state of the body musculature”

• Therefore, it is the body musculature which guides and directs the CNS

• Thus, tone inhibiting patterns are used to give the CNS the sensation of normal movements

• “ at any moment during the movement or a postural change, the CNS mirrors or reflects faithfully, the state of the body musculature”

• Therefore, it is the body musculature which guides and directs the CNS

• Thus, tone inhibiting patterns are used to give the CNS the sensation of normal movements

• Child must be active during treatment to achieve functional goals Voluntary control of normal responses is

encouraged

• Treatment and evaluation are ongoing

• Treatment if functionally-oriented

• Child must be active during treatment to achieve functional goals Voluntary control of normal responses is

encouraged

• Treatment and evaluation are ongoing

• Treatment if functionally-oriented



• NDT is appropriate for persons with sensorimotor dysfunction regardless of age and cognition

• Non-professionals can be an active participant in treatment

• NDT is appropriate for persons with sensorimotor dysfunction regardless of age and cognition

• Non-professionals can be an active participant in treatment



Treatment methods…Treatment methods…

• Modify sensory input through handling, positioning reflex inhibiting postures and use of key points of control

• Facilitate automatic reactions

• Normal movement patterns are integrated into developing nervous system

• Modify sensory input through handling, positioning reflex inhibiting postures and use of key points of control

• Facilitate automatic reactions

• Normal movement patterns are integrated into developing nervous system

OLD THEORY NEW THEORYHierarchical brain organization (Reflex model)

Systems Model

Normal postural reflex mechanism as the basis of normal movement

Postural control is learned together with the skill; feedback and feedforward mechanisms needed for efficient movement control

Static postures and positions used for treatment

Client is an active participant in the session

Progressing the client through normal developmental milestones

Developmental milestones serve as guidelines but should not be strictly adhered to

Development of control proceeds in a cephalocaudal direction

Control of movement develops in proximal to distal or distal to proximal directions

Work on components of motions which the child will then apply to function

Client must work on functional tasks to learn the skill

Evidence Evidence

The Effectiveness of the Bobath Concept in Stroke RehabilitationThe Effectiveness of the Bobath

Concept in Stroke Rehabilitation

• Boudewijn, K. et al. (2009)• Stroke. 2009;40:e89.• 16 studies involving 813 patients with stroke were included

for further analysis. • There was no evidence of superiority of Bobath on

sensorimotor control of upper and lower limb, dexterity,

mobility, activities of daily living, health-related quality of life, and cost-effectiveness.

• Only limited evidence was found for balance control in favor of Bobath.

• Boudewijn, K. et al. (2009)• Stroke. 2009;40:e89.• 16 studies involving 813 patients with stroke were included

for further analysis. • There was no evidence of superiority of Bobath on

sensorimotor control of upper and lower limb, dexterity,

mobility, activities of daily living, health-related quality of life, and cost-effectiveness.

• Only limited evidence was found for balance control in favor of Bobath.

Brunnstrom’s Movement Therapy

Brunnstrom’s Movement Therapy

Concepts and PrinciplesConcepts and Principles

History…History…

• Developed by Signe Brunnstrom, a physical therapist from Sweden

• Theoretical foundations: Sherrington Magnus Jackson Twitchell

• Developed by Signe Brunnstrom, a physical therapist from Sweden

• Theoretical foundations: Sherrington Magnus Jackson Twitchell

PremisePremise

When the CNS is injured, as in CVA, an individual goes through an “evolution in reverse”

– Movement becomes primitive, reflexive, and automatic

Changes in tone and the presence of reflexes are considered part of the normal process of recovery

When the CNS is injured, as in CVA, an individual goes through an “evolution in reverse”

– Movement becomes primitive, reflexive, and automatic

Changes in tone and the presence of reflexes are considered part of the normal process of recovery

Principles of treatmentPrinciples of treatment

Facilitate the patient’s progress throughout the recovery stages

Use of postural and attitudinal reflexes to increase and decrease tone of muscles

Stimulation of skin over the muscle produces contraction

Resistance facilitates contraction

Facilitate the patient’s progress throughout the recovery stages

Use of postural and attitudinal reflexes to increase and decrease tone of muscles

Stimulation of skin over the muscle produces contraction

Resistance facilitates contraction

Basic limb synergiesBasic limb synergies

• Mass movement patterns in response to stimulus or voluntary effort or both– Gross flexor movement (flexor synergy)– Gross extensor movement (extensor synergy)– Combination of the strongest components of the

synergies (mixed synergy)

• Appear during the early spastic period of recovery

• Mass movement patterns in response to stimulus or voluntary effort or both– Gross flexor movement (flexor synergy)– Gross extensor movement (extensor synergy)– Combination of the strongest components of the

synergies (mixed synergy)

• Appear during the early spastic period of recovery

Important! (Limb Synergies)Important! (Limb Synergies)

• Muscles are neurophysiologically linked and cannot act alone or perform all of their functions

• If one muscle in the synergy is activated, each muscle in the synergy responds partially or completely

• Patient CANNOT perform isolated movements when bound by these synergies

• Muscles are neurophysiologically linked and cannot act alone or perform all of their functions

• If one muscle in the synergy is activated, each muscle in the synergy responds partially or completely

• Patient CANNOT perform isolated movements when bound by these synergies

Basic limb synergies: UEBasic limb synergies: UE

ExtensorFlexor

Mixed synergy: UEMixed synergy: UE

Mixed synergy: LEMixed synergy: LE

Flexor Extensor

The Typical Hemiplegic PostureThe Typical Hemiplegic PostureHEAD Lateral y flexed toward the affected side

UPPER LIMB Scapula – depressed, retractedShoulder – adducted, IRElbow – flexedForearm – pronatedWrist – flexed, ulnarly deviatedFingers - flexed

TRUNK Lateraly flexed toward the affected side

LOWER LIMB Pelvis – posteriorly elevated, retractedHip – IR, adducted, extendedKnee – extendedAnkle – plantarflexed, inverted, supinatedToes - flexed

Attitudinal and postural reflexesAttitudinal and postural reflexes• Tonic Neck Reflexes

– Symmetric TNR

– Asymmetric TNR

• Tonic Neck Reflexes– Symmetric TNR

– Asymmetric TNR

stimulus response

Neck flexion Upper extremity flexionLower extremity extension

Neck extension Upper extremity extensionLower extremity flexion

stimulus response

Neck lateral rotation

Jaw side: upper extremity extension lower extremity flexionSkull side: upper extremity flexion lower extremity extension

• Tonic Labyrinthine Reflexes

• Tonic Lumbar Reflex

• Tonic Labyrinthine Reflexes

• Tonic Lumbar Reflex

stimulus response

supine Limbs tend to move in extension

prone Limbs tend to move in flexion

stimulus response

Trunk rotation (R) Increased flexor tone (R) UE and (L) LEIncreased extensor tone (L) UE and (R) LE

Trunk rotation (L) Increased flexor tone (L) UE and (R) LEIncreased extensor tone (R) UE and (L) LE

Associated reactionsAssociated reactions• Investigation by Walshe (1923)

– Associated reactions are released postural reactions deprived of voluntary control

• Investigation by Simons (1923)– Position of the head has a marked influence on

the outcome of the associated rections– Limb reactions evoked closely resemble tonic

neck reflexes

• Observations by Brunnstrom (1951,1952)– UE: movements employed elicited the same

reactions in the affected limb– LE: movements employed elicited opposite

reactions in the affected limb

• Investigation by Walshe (1923)– Associated reactions are released postural

reactions deprived of voluntary control

• Investigation by Simons (1923)– Position of the head has a marked influence on

the outcome of the associated rections– Limb reactions evoked closely resemble tonic

neck reflexes

• Observations by Brunnstrom (1951,1952)– UE: movements employed elicited the same

reactions in the affected limb– LE: movements employed elicited opposite

reactions in the affected limb

Associated reactionsAssociated reactions• Observations by Brunnstrom (1951, 1952)

– may be evoked in a limb that is essentially flaccid, although latent spasticity may be present

– may occur in the affected limb under a variety of condition: in the presence of spasticity, when a degree of voluntary control has been achieved, and after spasticity has subsided

– may be present years after the onset of hemiplegia

• Observations by Brunnstrom (1951, 1952)

– may be evoked in a limb that is essentially flaccid, although latent spasticity may be present

– may occur in the affected limb under a variety of condition: in the presence of spasticity, when a degree of voluntary control has been achieved, and after spasticity has subsided

– may be present years after the onset of hemiplegia

Associated ReactionsAssociated Reactions• Observations by Brunnstrom (1951,1952)

– repeated stimuli may be required to evoke a response

– tension in the muscles of the affected limb decrease rapidly after cessation of stimulus that evoked the associate directions

– attitudinal reflexes influence the outcome of associated reactions

• Observations by Brunnstrom (1951,1952)

– repeated stimuli may be required to evoke a response

– tension in the muscles of the affected limb decrease rapidly after cessation of stimulus that evoked the associate directions

– attitudinal reflexes influence the outcome of associated reactions

Associated reactionsAssociated reactions

• Homolateral Limb Synkinesis– The response of one extremity to stimulus

will elicit the same response in its ipsilateral extremity

• Raimiste’s Phenomenon– Resisted abduction or adduction of the

sound limb evokes a similar response in the affected limb

• Homolateral Limb Synkinesis– The response of one extremity to stimulus

will elicit the same response in its ipsilateral extremity

• Raimiste’s Phenomenon– Resisted abduction or adduction of the

sound limb evokes a similar response in the affected limb

Associated reactionsAssociated reactions

• Yawning– Flexor synergy is elicited during initiation of

yawn

• Coughing and Sneezing– Evoke sudden muscular contractions of short

duration

• Yawning– Flexor synergy is elicited during initiation of

yawn

• Coughing and Sneezing– Evoke sudden muscular contractions of short

duration

Hand reactionsHand reactions

• Steps to restoration of hand function (Twitchell, 1951)

1. Tendon reflexes return and become hyperactive

2. Spasticity develops; resistance to passive motion is felt

3. Voluntary finger flexion occurs, if facilitated by proprioceptive stimuli

• Steps to restoration of hand function (Twitchell, 1951)

1. Tendon reflexes return and become hyperactive

2. Spasticity develops; resistance to passive motion is felt

3. Voluntary finger flexion occurs, if facilitated by proprioceptive stimuli


4. Proprioceptive traction response can be elicited– Aka proximal traction response

– Stretch of flexors of one of the joints of the upper limb facilitates a contraction of the flexor muscles of other joints of the same limb thus producing total limb shortening

5. Control of hand without proprioceptive stimuli begins

4. Proprioceptive traction response can be elicited– Aka proximal traction response

– Stretch of flexors of one of the joints of the upper limb facilitates a contraction of the flexor muscles of other joints of the same limb thus producing total limb shortening

5. Control of hand without proprioceptive stimuli begins


6. Grasp is reinforced by tactile stimulus on the palm of the hand; spasticity declines

7. True grasp reflex can be elicited; spasticity further declines– Elicited by disctally moving deep pressure over

certain areas of the palm and digits» Catching phase: weak contraction of flexors and

adductors upon stimulus

» Holding phase: proceeds when traction is done on muscles activated in the catching phase

6. Grasp is reinforced by tactile stimulus on the palm of the hand; spasticity declines

7. True grasp reflex can be elicited; spasticity further declines– Elicited by disctally moving deep pressure over

certain areas of the palm and digits» Catching phase: weak contraction of flexors and

adductors upon stimulus

» Holding phase: proceeds when traction is done on muscles activated in the catching phase

Other hand reactionsOther hand reactions• Instinctive Grasp Reaction

– Stationary contact with the palm of the hand results to closure of the hand

• Instinctive Avoiding Reaction– With the arm elevated in a forward-upward

direction, the fingers and thumb hyperextend; stroking the palm in a distal direction exaggerates the posture

• Soque’s Finger Phenomenon– Elevation of the hemiplegic arm beyond the

horizontal results to estension and abduction of the fingers

• Instinctive Grasp Reaction– Stationary contact with the palm of the hand results

to closure of the hand

• Instinctive Avoiding Reaction– With the arm elevated in a forward-upward

direction, the fingers and thumb hyperextend; stroking the palm in a distal direction exaggerates the posture

• Soque’s Finger Phenomenon– Elevation of the hemiplegic arm beyond the

horizontal results to estension and abduction of the fingers

Recovery stages in hemiplegiaRecovery stages in hemiplegiaSTAGE CHARACTERISTICS

Stage 1 •Period of flaccidity•Neither reflex nor voluntary movements are present

Stage 2 •Basic limb synergies may appear as associated reactions•Spasticity begins mostly evident in strong components (flexor synergy appear prior to extensor synergy)•Minimal voluntary movement responses may be present

Stage 3 •Patient starts to gain voluntary control over movement synergies•Spasticity reaches its peak•Semi-voluntary stage as individual is able to initiate movement but unable to control it

STAGE CHARACTERISTICS

Stage 4 •Some movement combinations outside the path of basic limb synergy patterns are mastered•Spasticity begins to decline

Stage5

•More difficult combinations are mastered•Spasticity continues to decline

Stage6

•Individual joint movement becomes possible•Coordination approaches normalcy•Spasticity disappears: individual is more capable of full movement patterns

Stage7

Normal motor functions are restored

Treatment PrinciplesTreatment Principles

1. Treatment progress developmentally

2. When no motion exists, movement is facilitated using reflexes, associated reactions, proprioceptive facilitation and or exteroceptive facilitation to develop muscle tension in preparation for voluntary movement

1. Treatment progress developmentally

2. When no motion exists, movement is facilitated using reflexes, associated reactions, proprioceptive facilitation and or exteroceptive facilitation to develop muscle tension in preparation for voluntary movement


3. Resistance (proprioceptive stimulus) promotes a spread of impulses to produce a patterned response while tactile stimulation facilitates only the muscle related to the stimulated area

3. Resistance (proprioceptive stimulus) promotes a spread of impulses to produce a patterned response while tactile stimulation facilitates only the muscle related to the stimulated area


4. When voluntary effort produces or contribute to a response, patient is asked to hold the contraction (isometric). If successful, an eccentric (contracted lengthening) is performed and finally a concentric (shortening) contraction is done.

4. When voluntary effort produces or contribute to a response, patient is asked to hold the contraction (isometric). If successful, an eccentric (contracted lengthening) is performed and finally a concentric (shortening) contraction is done.


5. Facilitation is reduced or dropped out as quickly as the patient shows evidence of volitional control.

6. No primitive reflexes, including associated reactions, are used beyond Stage 3.

7. Correct movement once elicited is repeated

5. Facilitation is reduced or dropped out as quickly as the patient shows evidence of volitional control.

6. No primitive reflexes, including associated reactions, are used beyond Stage 3.

7. Correct movement once elicited is repeated

ReferenceReference

Bandong, A. (2008). Approaches to therapeutic exercise: Concepts, principles, and strategies. Power point lecture presentation in PT 154.

Bobath B (1990). Adult hemiplegia: Evaluation and treatment (3rd ed). Oxford, Heinemann Medical Books.

Levitt S (2004). Treatment of cerebral palsy and motor delay (4th ed). Singapore, McGraw-Hill Inc.

Sawner K & LaVigne J (1992). Brunnstrom’s Movement Therapy in hemiplegia: A Neurophysiological Approach (2nd ed). Philadelphia, J.B. Lippincott Company.

Bandong, A. (2008). Approaches to therapeutic exercise: Concepts, principles, and strategies. Power point lecture presentation in PT 154.

Bobath B (1990). Adult hemiplegia: Evaluation and treatment (3rd ed). Oxford, Heinemann Medical Books.

Levitt S (2004). Treatment of cerebral palsy and motor delay (4th ed). Singapore, McGraw-Hill Inc.

Sawner K & LaVigne J (1992). Brunnstrom’s Movement Therapy in hemiplegia: A Neurophysiological Approach (2nd ed). Philadelphia, J.B. Lippincott Company.

Documents

Approaches to Therapeutic Exercise and Activity for Neurological and Developmental Conditions (Bobath and Brunnstrom Approaches) PT 154: Therapeutic Exercise