Approach Used to Treat Patients with Motor Disorders Eg.Stroke, Etc

1. BRUNNSTORM’S
APPROACH

2. LEARNING OBJECTIVES
• History Of Approach
• Principles Of Approach
• Basic Limb Synergies

3. HISTORY
• Developed for hemiplegic patients by Signe
Brunnstrom,(1970) a physical therapist from Sweden.
• This approach was conceptualized from the theory of
reflex control and hierarchial control.
• Stroke patients undergo “Development in reverse” , so
the early reflexive movements should be seen as normal
process of development.

4. • In Normal persons, spinal cord and brain stem reflexes
become modified during development and their
components rearranged into purposeful movement by
the influence of higher centers.
• Since, reflexes represent normal stages of development,
they can be used when the CNS has reverted to an
earlier developmental stage as in hemiplegia.

5. PRINCIPLES
• Reflexes and whole limb pattern are the normal stages
of development. In stroke development occurs in reverse
pattern.
• Reflexes and primitive movement pattern should be used
to facilitate the recovery or voluntary movement after
stroke
• Proprioceptive and other somato-sensory stimuli can be
used to facilitate movement or tonal changes.

6. • Recovery in stroke takes place in Following sequence
Mass Movement
Stereotyped /Synergy
movement
Combination of two
pattern
Discreet Movement of
each joint

7. • New Correct movement achieved, Must be practiced to
be learned.
• Treatment progresses in following sequence.
Reflex Movement
Voluntary
Movement
Functional
Movement

8. • If Voluntary Efforts leads to response, The Following
sequence of contraction should be practiced.
Isometric (Hold)
Eccentric (Controlled
Lengthening)
Concentric (Shortening)

9. • Reduce or Wean off facilitation as soon as patient shows
evidence of voluntary control
• Correct elicited movement, Repeat to learn it.
• Practice should include functional activities.

10. DEFINITION OF TERMS/EVALUATION
• Synergy- is a movement pattern in which a group of
muscles acting as a bound unit in primitive and
stereotypical manner.
• The muscles are neurophysiologically linked and cannot
act alone or perform all of their function.
• If one muscle in the synergy is activated, each muscle in
the synergy respond partially or completely.

11. Associated reactions:
• Associated reactions are automatic responses of the
involved limb resulting from action occurring in some
other part of the body, either by voluntary or reflex
stimulation (e.g.resistance)

13. ASSOCIATED REACTIONS
• Yawning
• Flexor synergy is elicited during initiation of yawn
Coughing and Sneezing
• Evoke sudden muscular contractions of short duration.

14. Homolateral Limb Synkineses:
• It has been noted that a dependency exists between the
synergies of the involved upper and lower extremities.
• Thus, flexion of the involved upper extremity will elicit
flexion of the involved lower extremity.

15. Proximal traction Response
• Is Elicited by a stretch to the flexors muscles of one joint of
upper limb which initiate contraction of all flexors of that limb
including the fingers.
Grasp Reflex
When deep pressure is applied to the palm and move distally
over the hand and fingers, mostly on radial side adduction and
flexion of fingers occurs.

16. Instinctive grasp reaction
• It is a closure of hand in response to contact of
stationary object with palm of hand
Instinctive Avoiding reaction
A hyperextension reaction of the fingers and thumb in
response to foreward –upward elevation of arm.

17. Souque’s Phenomenon
• It is the automatic extension of the fingers when the
shoulder is flexed.
Raimiste’s Phenomenon
• Resisted abduction or adduction of the sound limb evokes
a similar response in the affected limb.

18. SENSORY EVALUATION
• Joint sense: With the patient seated and is blindfolded;
the affected upper limb is supported by the examiner and
moved to different positions asking the patient to perform
identical position with the unaffected extremity.

19. • Touch sensation: The palmer aspect of the finger tips
are touched with a rubber end of a pencil and the patient
is asked to determine without looking which fingertip is
touched.
• Sole sensation: the patient, without looking, is asked to
determine if an object is touching and pressing against
his sole of the foot or not and where.

20. COMPONENTS OF SYNERGY
• 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.

28. BRUNNSTORM’S STAGES OF RECOVERY
• 1-FLACCIDITY, NO MOVEMENT, AREFLEXIA
• 2-SPASTICITY BEGINS TO SET IN, SYNERGRY PATTERN
BEGINS TO DEVELOP
• 3-SPASTICITY INCREASES AND REACHES ITS PEAK,
VOLUNTARY CONTROL DEVELOP.
• 4-SPASTICITY DECREASES, SYNERGY DECREASES
ISOLATED MOVEMENT DEVELOPS
• 5- SPASTICITY CONTINUES TO DECREASE, SYNERGY
DECREASES, ISOLATED MOVEMENTS BECOMES
MORE PROMINENT.
• 6- SPASTICITY IS ESSENTIALLY ABSENT (NEAR
NORMAL)

29. LEVEL OF RECOVERY OF VOLUNTARY
MOVEMENTS
• Brunnstrom listed six stages of recovery for the arm, hand
and leg movements.
• Although stroke patients, on average, proceed through these
stages, a particular patient may stop at any stage.
• To date, there are no reliable ways to predict which patients
will recover voluntary movement and which will not.

32. SPEED TEST
• It can be used to assess spasticity during anyone of the
recovery stages, provided that the patient has sufficient
active ROM.
• The patient is seated on a chair without armrest leaning
against chair back and keeping the head erect.
• The two movements studied are:
(1) The hand is moved from lap to chin, requiring complete
range of elbow flexion.
(2) The hand is moved from lap to opposite knee, requiring
full range of elbow extension.

33. The hand is moved from lap to chin, requiring
complete range of elbow flexion

34. The hand is moved from lap to opposite knee,
requiring full range of elbow extension.
A stopwatch is used and the number of full strokes completed in 5
seconds is recorded, first on the unaffected then on the affected side.

35. IMPORTANT INSTRUCTIONS
• Make the patient physically and psychologically
comfortable.
• The sequential aspects of the motor evaluation are
used to determine the patient's level of motor
control.
• No movements beyond the patient's capabilities are
demanded.
• No facilitation is used during the evaluation.

36. • Each motion is demonstrated to the patient, and
he does it with his unaffected extremity before he
attempts it with his affected one.
• Instructions should be given in functional terms.
For example, to test the flexor synergy of the
upper extremity, say "Touch behind your ear"
• For the extension synergy, "Reach out to touch
your [opposite] knee" (Brunnstrom, 1966)

37. TREATMENT PRINCIPLES
(1) 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.
(2) The responses of the patient from such facilitation combine
with the patient's voluntary effort to produces semivoluntary
movement.
(3) Proprioceptive and exteroceptive stimuli assist in eliciting
the synergies.

38. (4) When voluntary effort appears:
a) The patient is asked to hold (isometric) the contraction.
b) If successful, he is asked for an eccentric (controlled
lengthening) contraction.
c) Finally, a concentric (shortening) contraction.
d) Reversal of the movement between the agonist and antagonist.
(5) Facilitation is reduced or dropped out as quickly as the patient
shows voluntary control (primitive reflexes & associated reactions).
(6) Correct movement is repeated.
(7) Practice in the form of ADL.

39. TREATMENT

40. TREATMENT
• The principal focus of treatment is on the normal movement
developmentally from its reflexive base to voluntary control
of individual motions that can be used functionally.
• Used to develop tone in flaccid stage of UMN syndrome,
arising from pure pyramidal lesion like stroke /TBI.

41. • Techniques utilizes reflex responses which is trained
under voluntary control.
• Associated reactions are used to develop further
functional ability.
• Eg. Hyper-extension of thumb producing release of
finger flexors.

42. • The Main Goal of this approach is to facilitate the
patients progress through the recovery stages that
occurs after the stroke.
• 1-Bed Positoninig
• 2- Bed Mobility
• 3- Trunk Control
• 4- Techniques

43. BED POSITONING
• Begins Immediately after the onset of the stroke when
the patients is in flaccid stage.
• Limbs should be placed in most favorable position
without interference from the hypertonic muscles.
• In absence of proper bed positioning the lower limb
tends to assume a position of hip external rotation,
abduction and knee flexion.

44. • In case of External Synergy dominates in lower limb
• The recommended Position is
• Supine
• Slight Flexion of Hip and knee(using towel or pillow)
• Use towel, pillow, Sand bag to prevent external rotation
and abduction
• Ankle supported in neutral position

45. • In case of Flexor Synergy dominates in lower limb
• The recommended Position is
• Supine
• Knee in extension
• Hip External rotation should be prevented
• Ankle in neutral

46. • The affected upper limb is supported on a pillow in a
position that is comfortable for the patient.
• Abduction of the humerus must be avoided.
• Patient is instructed to use the unaffected hand to
support the affected arm while moving in the bed.

47. 2-BED MOBILITY
• Turning towards affected side is easier than turning
towards the unaffected side..
• To turn towards unaffected side-the affected upper
limb is grasped by the unaffected hand both the limbs
are elevated upto 80-90 degree of shoulder flexion with
elbow extension.
• The affected lower limb is in slight flexion at hip and
knee (supported by the therapist).

49. • Patient turns the unaffected side by swinging the arms
and affected knee across the body towards affected side.
• The momentum produced by upper limb helps in turning
upper body and pelvis.
• As the patient develops control therapist support is
withdrawn

50. REHABILITATING TRUNK CONTROL
• Some patients with hemiplegia may have poor trunk
control and may require training to enable them to bend
over to retrieve an object from the floor or to dress their
lower extremities.
• To elicit balance responses, the patient is gently pushed
in forward, backward, and side-to-side directions

51. • The patient is pushed only to the point at which he is
able to hold the position and then regain upright posture
and is guarded throughout.
• Training then progresses to promote trunk flexion,
extension, and rotation.

52. • The patient is asked to assume sitting position, lifting the
affected upper extremity by the unaffected one and do
actively trunk movements in all directions.

53. TECHNIQUES
• Associated Reaction
• Homolateral Limb Synkinesis
• Proximal Traction Response
• Grasp Reflex
• Instanctive grasp reaction
• Souques phenomenon
• Remistes Phenomenon
• Auditory Stimuli (Verbal Clues)
• Visual Stimuli (Use of Mirror)

54. UPPER EXTERMITY RX
• Treatment Protocol Should be decided in reference to
Brunnstorm Stages of recovery.
• Using two Approaches at a same will be beneficial
According to researches.
• Use Muscle Stimulator For Denervated Ms.
• Use Faradic Stimulation For Strengthening
• Use of Functional Electrical Stimulation.

55. STAGE 1 AND 2
• Aim is to elicit Tone and avoid synergy in future
• To elicit flexor tone tap over upper and middle trepizius,
rhomboids and biceps.
• To elicit extensor synergy tap over triceps stretch
serratus anterior passive movements.
• Facilitation techniuqes and proper bed positonig to avoid
synergy to develop.

58. *Use Stick Diagrams

59. • Positioning while lying on the affected side: When lying
on the weaker side, one or two pillows are placed under
the head, the weaker shoulder is positioned comfortably on
a pillow, the stronger leg is forward on one or two pillows,
and the weaker leg is straight out. Pillows are also placed
in back and in front of the body

60. • Sitting(In bed or Wheel chair)
a. Patient should sit upright with trunk and head in midline
alignment
b. Symmetrical weight bearing on both the buttocks
should be encouraged
c. Leg should be in neutral position
d. While sitting on chair hip and knee should be positioned
in 90 degrees of flexion

61. STAGE 3
• Positoning
• Weight Bearing exercises
• Galvanic Stimultion if ms. Is denervated
• Faradic Stimulation if pt shows sign of voluntary control.
• Re-education by using Board, Skates.
• Functional EMS
• NMES

62. STAGE 4 AND 5
• Perform Figure of 8 on board
• Hand to chin
• Hand to ear
• Hand to opposite elbow
• Hand to opposite shoulder
• Hand to forehead
• Hand to back of head
• Strengthning
• Re education
• Prehension activity using peg board

63. STAGE 6
• Return to function phase
• Goal Specifc activity
• Agility training
• Although few patients can reach this stage (only if
appropriate rx is provided in a appropriate time)

64. THANK YOU
BE SAFE
Maintain social distancing