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brunnstorm approach

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  1. 1. Brunnstrom’s Approach By Abraham M. Joshua Associate Professor and Head Department of Physical Therapy Deputy Chief Superintendent (Manipal University) Kasturba Medical College, Mangalore
  2. 2. Contents Introduction General Principles Brunnstrom’s Recovery Stages Principles Of Evaluation Training Procedures
  3. 3. Introduction • Signe Brunnstrom developed this approach in early 1950’s. • Brunnstrom used motor control literature and observations of the patients. • Procedures - in a trial and error fashion. • Later modified- in the light of neurophysiological knowledge.
  4. 4. • Successful procedures were replicated from patient to patient. • The goals set for the patient should be achievable. • Techniques as training procedures. • Movement recovery tends to be stereotypic. • Patients exhibits only few stereotypic movement patterns - Basic Limb Synergies (BLS).
  5. 5. • BLS are considered to recover first; dominant muscle groups controls the pattern of responses and as recovery progresses, independent voluntary movements begin. • Spasticity - key to progression from synergistic to non-synergistic movement.
  6. 6. General Principles • As development progress, reflexes become modified and their components rearranged into purposeful movement through the influence of higher centers. • Reflexes and whole-limb movement patterns represent normal stages of development. They are considered to be “normal” when the CNS has reverted to an earlier development stages.
  7. 7. • Hierarchy in the central nervous system is reflected in normal development as well as in hemiplegia. • Parallel between recovery from stroke and normal development. • From this premise, reflex activity is used as the basis for voluntary movement and treatment procedures dependent on the stage of recovery reached i.e. reflexes and primitive movement patterns to facilitate recovery.
  8. 8. • Sub-cortical motion synergy that can be elicited on a reflex basis may serve as a wedge by which a limited amount of willed movement may be learned. i.e.; reflexes to be used to elicit movement when none exists as part of a normal developmental sequence. • Facilitation of recovery process is seen to take place in developmental stages. Stages have only to be achieved and not perfected. • Patient has to be encouraged to undertake activities in the sitting position as soon as possible.
  9. 9. • Newly generated correct motions must be practiced to be learned and practicing within the context of daily activities enhances further learning. • Proprioceptive and exteroceptive stimuli can be used therapeutically to evoke desired motion or tonal changes. • Based on the observations of recovery following stroke, this approach makes use of associated reactions, tonic reflexes and the development of basic limb synergies to facilitate movement. • Use of such procedures is temporary.
  10. 10. Basic Limb Synergies: • Normal subject - synergistic motor behavior • Normal synergistic movement are limitless. • Coupling together of muscles in an orderly fashion for producing purposeful movements with maximum precision and minimum waste of energy. • Stroke patient exhibit only few movement patterns which are stereotypic in nature, referred as BLS. • BLS do not permit different combination of muscles.
  11. 11. • The group of muscles constituting a BLS act together as a bound unit. • BLS - gross flexor (flexor synergy) or gross extensor movement (extensor synergy). • There are four BLS. Two for UE & two for LE. • BLS are considered as primitive, automatic and reflexive, highly similar. • Reflects the loss of inhibitory control exerted by higher centers. • Appear during early spastic period and can be evoked volitionally or reflexly.
  12. 12. • The movement within the BLS is considered easier to achieve. • BLS have strong (dominant) and weak components. • During the early recovery stage almost all patients tend to initiate movement pattern by strong component. • Influence of tonic reflexes on BLS.
  13. 13. Extremity Type of BLS Components forming synergy Strong and weak muscle components Upper limb Flexor synergy 1.Retraction and/or elevation of the shoulder 2.External rotation of the shoulder 3.Abduction of the shoulder to around 90° 4.Flexion of the elbow to an acute angle 5.Full-range supination of the forearm. 6.Flexion of the wrist and the digits frequently seen, but is by no means universal. Elbow flexors and shoulder elevators are the strong components. Shoulder abductors and external rotators and supinators are the weak components.
  14. 14. Extremity Type of BLS Components forming synergy Strong and weak muscle components Upper limb Extensor synergy 1.Protraction of the shoulder 2.Internal rotation of the shoulder 3.Adduction of the arm in front of the body. 4.Extension of the elbow to complete range. 5.Full-range pronation of the forearm. 6.Extension of the wrist with fist closure frequently seen, but is by no means universal. Shoulder addutors and internal rotators are the strong components. Elbow extensors are the weak component.
  15. 15. Typical Attitude of Arm
  16. 16. Extremity Type of BLS Components forming synergy Strong and weak muscle components Lower limb Flexor synergy 1.Flexion of the hip. 2.Abduction and external rotation of the hip. 3.Flexion of the knee to about 90°. 4.Dorsiflexion and inversion of the foot. 5.Dorsiflexion of the toes. Components of flexor synergy tend to be weaker with respect to extensor synergy. Flexor synergy is usually initiated by hip flexion.
  17. 17. Extremity Type of BLS Components forming synergy Strong and weak muscle components Lower limb Extensor synergy 1.Extension of the hip. 2.Adduction and internal rotation of the hip. 3.Extension of the knee to complete range. 4.Plantar flexion and inversion of the foot. 5.Plantar flexion of the toes is frequent, but is by no means universal. Knee extensors are the strongest and usually the patients tend to use it to initiate the extensor synergy. Even hip adductors and plantar flexors are strong components.
  18. 18. Typical Attitude of Lower Limb
  19. 19. • Movements of a BLS occur in the opposite direction from those of the antagonistic synergy. • Inversion is a common component. • Antagonist of the dominant component of one synergy is the weakest of the other synergy. • The weakness of the components can be explained neuro-physiologically (arises as a result of stretching of the spastic antagonist when movement is attempted). • Some amount of spasticity is likely to occur in the weak muscles.
  20. 20. • When the BLS dominate, the quantity and the quality of movements depend on the relative strength of individual components of the synergy and the manner in which the components interact. • Typical arm posture results from the combination of strongest components of BLS. • In the lower extremity the attitude will be extensor in nature owing to the domination of extensor synergy.
  21. 21. • Strong extensor synergy components in the lower limb makes the patient fail to achieve hip abduction necessary for standing balance and ambulation. • Knee extensors are the most dominant and most spastic of the extensor synergy, followed closely by the hip adductors : makes standing and walking difficult.
  22. 22. Evolution and Dissolution of Nervous system: • Hughling Jackson (British neurologist): the phylogenetic organization of the nervous centers occurs on three levels. • This organization is recapitulated during ontogenesis. • These three levels or groups of nervous centers are integral part of the fully developed CNS of a normal subject.
  23. 23. • Three levels - lowest, middle & higher motor centers. – Lowest motor centers: few movement combinations that are mostly automatic in nature. – The middle motor centers re-represent :more combinations that are more voluntary and less automatic in nature. – The higher motor centers :numerous combinations which are mostly voluntary.
  24. 24. • Following pathologies like CVA the nervous system reverts to a lower level of evolution -“dissolution” of the nervous system or “evolution in reverse”. • Patients with severe CNS involvement must rely on the lowest motor centers which provide few movement combinations that are automatic in nature. • Less severe involved patients may recover sufficiently to utilize the middle motor centers. • However, full motor recovery needs normal functioning of the middle motor centers with least involvement of highest center.
  25. 25. Postural reflexes • Postural or attitudinal reflexes such as TNR, TLR and Tonic Lumbar Reflexes get integrated as the nervous system matures. • The tonic neck reflexes are evoked by neck movements : – Symmetrical or asymmetrical. – The tonal variation produced by STNR is identical on both left and right side of the body. – For ATNR the tonal variations are opposite on the left and the right limbs • TLR evoked by changes in the position of the head in space.
  26. 26. • Tonic lumbar reflexes are elicited by changes in position of the upper part of the body with respect to the pelvis. • These attitudinal reflexes easily demonstrable in certain CNS pathologies. • If strong, they make the voluntary movements difficult. • They are still a part of the normal neurophysiological equipment and under various circumstances their facilitating effects can be evident.
  27. 27. • Postural reflexes are exaggerated (in stroke/CP/TBI etc)- released reflexes. • May make the voluntary movements difficult or impossible. - For instance, effects of TLR on elbow extension. Associated Reactions: “Reflex tensing of muscles or involuntary movements.” • Frequently seen in patients with hemiparesis. • Voluntary forceful movements may elicit such reactions in the affected side. • Tensing or movement usually appears within few seconds and may occur in several or all the joints of the affected limb or limbs.
  28. 28. • The muscular tension may continue even after the stimulus that evoked the reaction ceases. • Riddoch and Buzzard (1921) defined it as “automatic activities which fix or alter the posture of a part or parts when some other part of the body is brought into action by either voluntary effort or reflex stimulation”. • More in spastic limb. • Walsh (English neurologist): “released postural reactions deprived of voluntary control”. • Usually flexor or extensor in nature and may require repeated stimuli. • Yawning, sneezing and coughing elicits it.
  29. 29. • Raimiste (French neurologist): reported many associated reactions. • In supine position, strong resistance to noninvolved side hip adductors moved the affected side hip into adduction and resistance to hip abductors elicited abduction movement of affected hip. (Raimiste’s hip adduction and abduction phenomenon respectively). • Adduction appears readily as compared to abduction.
  30. 30. • The attitudinal reflexes are believed to influence the outcome of associated reactions. • Brunnstrom: In the upper limb the reactions were of the same type as the movement; whereas, for flexor and extensors of lower extremity the reactions were opposite. • However, a mutual dependency appears to exist between the synergies of the affected side upper and lower extremities which she referred as “homolateral limb synkinesis” i.e. flexion of affected upper or lower limb tends to evoke or facilitate flexion of the ipsilateral limb and extension tends to evoke extension.
  31. 31. • A reaction alike Raimiste’s phenomenon was observed by Brunnstrom in the upper extremity (shoulder adduction and abduction phenomenon). • According to Raimiste, such tendency to move both legs simultaneously is present even in normal subjects. However, conscious effort can easily prevent it.
  32. 32. Hand reactions and restoration of hand functions • In humans, the evolution of grasping function may be traced back to simple stretch reflex. • Denny-Brown(1956) & Twitchell (1958): normal maturation and activities of higher centers on lower centers transforms such reactions into more and more elaborate mechanisms until normal adult hand functions evolve. • Twitchell (1951) identified seven steps in the restoration of hand functions which proceeds in a manner that closely resembles the evolutionary one.
  33. 33. • Recovery can cease before the last stage is reached (Twitchell). • Those patients who exhibited the true grasp reflex could progress to full recovery (Twitchell), i.e. with the affected hand they could perform the skills equal to that of the uninvolved hand. • Neurophysiologically, the restoration of hand function in stroke patients follows a sequence.
  34. 34. Stretch reflex Proprioceptive traction response True grasp reflex Instinctive grasp reaction Instinctive avoidance reaction Normal hand functions
  35. 35. Stage Features I Tendon reflexes return and become hyperactive. II Characterized by development of spasticity in the long flexors which can be felt as resistance on passive motions. III Proprioceptive stimuli facilitate voluntary finger flexion. IV Characterized by elicitation of proprioceptive traction response, i.e. a stretch of the flexor muscles of any one joint of the limb evokes or facilitate contraction of the flexor muscles of all the joints. The body righting reactions have either facilitating or inhibiting effect on this response. V Control of hand movements possible without proprioceptive stimuli. VI During this stage, grasp is greatly reinforced by tactile stimuli in the palm of the hand and is also characterized by decline of spasticity. VII True grasp reflex is elicited with further decline of spasticity. Has two phases, a catching phase and a holding phase. Difference between grasp reflex and proprioceptive traction response - the former is evoked by a tactile stimulus and the latter is elicited by a stretch.
  36. 36. Instinctive grasp reaction: • Stimulus - a stationary contact of any solid object with the palm of the hand. • Response - an involuntary fist closure with the patient unable to release the object. • Patient may not have any difficulty to open or close the hand in the absence of the object. • Seen at birth, but subsequently disappears as the brain matures. • Pathologies affecting the frontal cerebral lobe cause the reappearance of the same.
  37. 37. Instinctive avoiding reaction: • Seen in patients with parietal lobe lesions. • If arm is held in a forward-upward direction, fingers and thumb tends to be held in extension. • Stimulus- a stroking of a solid object on the palmar surface towards the distal direction. • Response is exaggeration of the hand posture. Not an uncommon feature in children with cerebral palsy. • Neurophysiologically, both instinctive grasp and instinctive avoiding reactions are considered as “Transcortical Release”.
  38. 38. BRUNNSTROM’S RECOVERY STAGES • Brunnstrom: stereotyped sequence of events takes place during recovery. • Seven stages. • Depending on the severity of the insult and the degree of sensory involvement recovery may get arrested at any stage in the process. • Stages cannot be skipped. • In some cases, especially when the insult is minor, the recover may proceed rapidly with no distinct observable stages. • Believes that the stages of recovery resemble the normal infantile motor development.
  39. 39. Recovery stage Features Stage I Seen soon after the acute episode; affected limbs are essentially flaccid; no voluntary or reflexive movement possible. Stage II As recovery begins, BLS or some of their components appear as associated reaction or some of the components of BLS appears with considerable voluntary effort; spasticity begins to develop (particularly in the dominant components). Stage III The patient gains voluntary control on B.L.S; full range of all synergy components is not mandatory; spasticity reaches its peak; considered as the semivoluntary stage. Stage IV Some movement combinations that do not follow the paths of B.L.S are mastered, first with difficulty and then with ease; spasticity begins to decline; the influence of spasticity on nonsynergistic movements is readily observable
  40. 40. Recovery stage Features Stage V As recovery continues, more difficult movement combinations away from the path of BLS are mastered; dominance of BLS over motor control reducing; spasticity continues to decline. Stage VI Individual joint movements possible; coordination reaching normalcy; absence of spasticity. Stage VII Normal motor functions restored.
  41. 41. Principles of Evaluation • Purpose of evaluation is to note the degree of recovery and the evaluation procedure should be based on recovery stages. • Evaluation procedure to be brief and easy to administer, minimizing overly fatigue of patient and waste of time available for treatment. • The traditional neurological examination procedures like MMT for muscle strength evaluation does not give any information about the stage of recovery and the real muscle strength. • Traditional MMT will create errors in grading muscle strength.
  42. 42. • Brunnstrom had developed and tried several evaluation forms and found many of them unsatisfactory or cumbersome. • Later, she revised the form and produced a simplified one. • This form had only minimal test items which helps to identify the level of motor control and stage of recovery. • Patients might be in transition phase. • Stage of recovery for upper limb and lower extremities may not be alike.
  43. 43. • Patient should be physically and mentally comfortable prior to evaluation. • No facilitation techniques used and no movements beyond his capabilities are demanded. • The evaluation of upper limb in sitting. It consists of test for passive motion sense of the joints and the level of motor control. • Sensory evaluation should precede the motor evaluation. • Each motion has to be demonstrated to the patient prior to motor evaluation. • Clear and simple instructions.
  44. 44. • Percentage of ROM in each joint is recorded. • Speed test for movement, if the patient is in 4-6 stages, i.e. hand from lap to chin or hand from lap to opposite knee in five seconds. • Upper limb evaluation also consists of test for finger tip recognition, wrist stabilization for grasp and wrist flexion, extension and circumduction. • For digits, hand functions such as mass grasp, mass extension, hook grasp, cylindrical grasp, prehension, individual finger movements and skilled activities like buttoning and unbuttoning shirt.
  45. 45. • Evaluation of trunk and lower limb is performed with patient sitting on a chair and in standing. • Even for trunk and lower limb, passive motion sense, sole sensation, trunk balance and the level of motor control to be tested. • Trunk balance can be tested both in sitting with no back support and in standing. • The type of ambulation i.e. whether with or without brace or cane or support, or escort also to be assessed.
  46. 46. • Ankle, knee and hip attitude in stance phase and swing phase, arm swing, cadence and steps per minute are the components analyzed under gait assessment
  47. 47. Stage Extremity Test item Stage IV Upper extremity 1. Hand to sacral region or placing the hand behind the body 2. Elevation of the arm to a forward-horizontal position 3. Pronation and supination of forearm with elbow at 90° Stage V Upper extremity 1. Arm raising to a sideward- horizontal position 2. Elevation of the arm to a forward and over head position 3. Pronation and supination of forearm with elbow extended with arm forward-horizontally elevated.
  48. 48. Stage Extremity Test item Stage IV Lower extremity 1. Ability to flex the knee beyond 90° with the foot sliding backward on the floor 2. While the patient is sitting Voluntary dorsiflexion of the ankle without lifting the foot off the floor in sitting Stage V Lower extremity 1. Isolated non-weight bearing knee flexion with hip in extension or near extension in standing 2. Isolated dorsiflexion of the ankle with knee extended and the heel kept forward as if for heel strike
  49. 49. TRAINING PROCEDURES • Therapist must have adequate confidence in her knowledge, skill and judgment. • Essential to have a constructive patient- therapist relationship. • Both for evaluation and treatment, if the patient lacks confidence in the therapist, he may feel ill at ease and will be reluctant to make the effort required. • During training sessions, tasks that the patient can master or almost master will be demanded, as repeated failures may lead to frustration and disappointment.
  50. 50. Recommended bed posture and bed exercises • When the flaccid condition prevails, the positioning of the limbs in the bed - most favorable way without interference by spastic muscles. • In supine: Lower limb has a tendency for extensor posture with hip in abduction and lateral rotation- slight hip and knee flexion maintained by a small pillow under the knee with lateral support of the knee to prevent hip abduction and external rotation is recommended. • No clothing should be in contact with the foot.
  51. 51. • The affected upper extremity is supported on a pillow in a position that is comfortable for the patient. • To avoid inferior subluxation of the glenohumeral joint, attention has to be given not to keep the humerus in abduction with respect to the scapula. • Avoid traction on the affected arm and he should be instructed to support his affected arm with the normal hand. • While the flaccidity predominates, passive motions of the limb are first carried out and then developed into active assisted movements.
  52. 52. • The program is expanded to include head, neck, and trunk movements. The patient should be taught to move around in bed, sit up and turn to side lying while protecting the affected arm. • Turning can be promoted with the affected arm kept close to the body, thus rolling over his affected arm. • If the patient complains of pain in the shoulder, then the patient can be taught to roll to affected side with the affected arm held at the wrist by the sound hand.
  53. 53. • For many patients, turning to the sound side difficult. • Turning to sound side should be performed by bringing the affected limb into partial flexion with momentary stabilization of the position by the therapist. • Then, the patient should attempt turn over by swinging arms and the affected knee across the body. • Later, as the control improves it should be performed as a continuous movement from the supine to the side lying with no assistance. • As soon as possible, treatment should incorporate trunk and neck exercises in sitting position.
  54. 54. Transition
  55. 55. • Exercises in sitting aims to: – improve trunk balance, – gain control on trunk movements – provide a face to face encounter (valuable especially in aphasic) and – facilitates opportunity to gain voluntary control of affected upper extremity. • Ensure adequate head, neck and trunk flexibility for trunk balance. • In sitting, trunk rotations can be performed by placing patient’s arms close to the body.
  56. 56. • Initially, trunk rotation should be performed gently within small range and then the range should be gradually increased. • Throughout the movement, the patient should look straight ahead in order to provide certain amount of neck mobilization. • Many patients may have a tendency to list or lean towards the affected side. • Listing phenomenon can be as a result of perceptual deficits or due to lack of activity of affected side trunk muscles to check the movement when COG shifts to sound side.
  57. 57. • Essential to overcome uneven weight bearing. • Evoking balance responses by deliberately disturbing the COG by “pushing the patient” in different directions particularly in the direction towards he tends to list helps to minimize the listing tendency and promotes trunk symmetry. • Cradle his affected arm when perturbations are given.
  58. 58. • If listing due to perceptual deficiency, attempts to be made to help him gain a better appreciation of spatial relations. • Reinforcement of afferent impulses from the receptors for position, kinesthetic, pressure and light touch senses and use of visual clues. • Other methods to overcome listing: – Repetitive head and trunk movements, – use of temporary raise under the buttocks on one side or other and a light touch by the normal hand on a vertical or horizontal stationary object.
  59. 59. • Trunk inclination exercises for gaining trunk control. i.e. bending the trunk forward and obliquely forward on his hips with little or no forward flexion of the spine can be incorporated to the treatment. • Emphasis to cradle affected arm. • Therapist may have to guide the trunk and arm movements by holding her hands under the patient’s elbow (also helps to gain Glenohumeral and Scapular motions). • While sitting, head and neck movements may be utilized to facilitate shoulder girdle movements over which patient may have little or no control.
  60. 60. • Resistance to lateral head motion towards the affected side may promote elevation of scapula. • Emphasizing on isometric or eccentric muscle contraction by giving commands like “hold” or “don’t let me pull your head away from your shoulder” followed by concentric muscle contraction by commands like “get your shoulder closer to the ear” can be utilized to attain control over shoulder elevation.
  61. 61. Upper Limb Training: • Voluntary control or at least partial control of BLS is a prerequisite. • Just as in normal motor development, it is not essential to perfect the activities before attempts are made for more advanced stages of motor developmental sequences. • If the patient is in flaccid stage, to initiate BLS, associated reactions or attitudinal reflexes can be utilized.
  62. 62. • Such reactions enable background tension in muscles and then to gain voluntary control over BLS, volitional effort to be superimposed. • Usually, the first associated reactions in upper extremity are observed in flexors. • Once the patient is able to initiate movement on a voluntary basis, reflex assistance has to be withdrawn and movement patterns that deviate from BLS to be introduced. • Movement therapy becomes more meaningful only if the patient utilizes BLS or its components for functional activities.
  63. 63. • Though, the BLS can be utilized for many household activities, there are controversies regarding its long-term advantages and disadvantages. For instance, the possibility of one-armed-ness or neglect can be overcome by early usage of BLS. • Long term use of BLS for functional activities may promote excessive reliance on the BLS which may reinforce the components of BLS, in turn hindering the potential of further recovery. • Use of the BLS in practical activities must be controlled, based on therapist’s knowledge of the individual patient.
  64. 64. • In the early stage, rapid passive range of motion exercise may evoke spasticity in the dominant components of the BLS which the patient may be able to sense and be able to assist in achieving the movements. • However, the efforts must be modulated and very gentle passive movements for gaining more normalized tone has to be introduced, if excessive spasticity develops in them.
  65. 65. • Initially shoulder girdle movements such as elevation, depression, retraction and protraction can be stressed. • Later, shoulder flexion movements have to be performed bilaterally and then unilaterally. • If the patient is unable to perform shoulder movements, then the therapist will have to assist or guide the movement and simultaneously she might have to use percussion or cutaneous stimulation over the muscles in order to activate them.
  66. 66. Shoulder pain and subluxation: • To necessitate normal glenohumeral rhythm, the therapist may have to guide the patient’s scapula into upward rotation during shoulder movements. • When passively mobilizing, if the patient complaints of shoulder pain secondary to stretching of spastic muscles, then mobilization of the shoulder joint without forceful stretching of tense muscles have to be attempted. • Anticipation of pain – increase the tension in the spastic muscles.
  67. 67. • For such patients, attempts to be made to guide the movement of the arm with respect to the trunk without the patient sensing the movement of the arms. • Trunk rotation exercises help to utilize the tonic reflexes to alternatively increase and reduce the tension in the pectoralis major muscle enabling a larger range of shoulder abduction without pain. • Once no pain on passive movement, active assisted movements of the arm with respect to the trunk can be started.
  68. 68. • Even promoting activity in all the components of flexor synergy -essential for a pain free shoulder movement. • As the training progresses, however, emphasis is also given in developing extensor synergy and eventually, both the synergies are combined in a “roundabout” fashion for producing painless movements. • Activation of muscles around the shoulder joint is needed- to maintain the integrity of the joint.
  69. 69. • Normal tone and activity of the rotator cuff muscles, especially supraspinatus plays an important role in preventing the glenohumeral separation. • Flexor synergy can be used to facilitate background tension in the supraspinatus and other external rotators. • Later, a more isolated contraction of the external rotators should be stressed.
  70. 70. Techniques for improving motor control: • Use of strong or dominant components of a synergy to strengthen the weaker ones. For example, “waist squeezing” or pronation of forearm prior to the patient’s effort for elbow extension. • The movements are guided in the beginning before active assisted, active and resisted exercises are given. For example, when the patient performs bilateral “classic rowing exercise” , the therapist can guide the movement and later, resistance can be applied to the affected side.
  71. 71. • In bilateral rowing exercise, the push phase is initiated and executed using the flexor synergy and the pull phase using the extensor synergy of the affected extremity. • Local stimulation can also facilitate muscle contraction. E.g. vigorous back and forth stroking of the skin over the weak muscles and use of proprioceptive or proximal traction response (mentioned earlier) to facilitate muscle contraction. • Use of visual guidance and attitudinal reactions.
  72. 72. • Use of postural reactions such as tonic neck, tonic labyrinthine and tonic lumbar reflexes for providing a background tension in the weak muscles. • Isometric and lengthening contractions to be attempted before shortening contractions. “Place after positioning” the affected limb. • In order to gain better motor control “reversal of movement direction” can be utilized. E.g. “push and pull exercise” in sitting can be used to strengthen weak extensor synergy and can also promote better control of flexor and extensor synergy.
  73. 73. • Weight bearing through affected arm, in sitting or other functional positions promotes background activity in the weak synergic muscles. • As the patient gains more control over the movement, the therapist’s assistance and use of facilitatory and postural reflexes should be withdrawn.
  74. 74. Serratus Anterior Training: • Flexor synergy may enable 90° abduction at shoulder. • On inspection and palpation: strong contraction of Trapezius and Deltoid muscles with winging of scapula. • Idle nature of Serratus Anterior. Factors: – Excessive spasticity in pectoralis major muscle and – painful range of motion at the shoulder for raising the affected arm overhead. • Certain amount of control of muscles belonging to the two BLS of upper extremity and mobility of scapula are the pre-requisites for facilitating Serratus Anterior.
  75. 75. • To facilitate this muscle: – patient should be in sitting position with the arm supported in a forward-horizontal direction. He should be requested to reach forward, which may be assisted and mean time therapist should briskly stretch the serratus muscle. – Commands like “don’t let me push your arm back” should be simultaneously given. – Isometric and later eccentric activity of the muscle. – If pectoralis major muscle overacts, the affected arm should be brought into more abducted position and the facilitation technique should be repeated.
  76. 76. – Once isometric and eccentric muscle contractions are possible, concentric exercises as “arm to ear”, “arm to opposite shoulder” and eventually “arm above head” should be taught. – To gains more voluntary control, “reversal of movement” should be introduced. – Guidance, assistance and resistance offered by the therapist for the movement synergies and their individual components should be gradually withdrawn.
  77. 77. Upper limb training for recovery stages IV & V • Certain level of control of two BLS is a pre- requisite. • Training procedures aim at -modifying the available motor responses and reinforcing the willed impulses -to overcome the still existing, although diminishing linkage between BLS. • Movement combinations that deviate from the paths of BLS must be introduced in order to -break up the strong linkage. • Activate those muscles which do not belong to BLS.
  78. 78. • Patients may find difficulty in initiating movements away from the path of either synergy. • Functional activities which resemble the BLS can be used as variations in movement direction. For instance, – Variation of the “classic rowing” pattern. Incorporating shoulder abduction during the pull phase and shoulder adduction during the push phase for variations. – Similarly, modification of either synergy to bring the hand to mouth (usually, the patient brings his hand to the mouth with simultaneous abduction of the arm and the head turns to meet the hand), opposite shoulder, forehead and top and back part of head. Subject to be directed to press his elbow firm against the side of the body.
  79. 79. • Use proprioceptive, exteroceptive & hold after positioning. • The desired movement paths have to be demonstrated first (by passive movements) to provide sensory impulses to facilitate better control over the attempted voluntary movement. • Training procedures also include bringing hand first to ipsilateral ear and then to contralateral ear and also promote back and forth stroking movement.
  80. 80. • Stroking can be performed by the use of palm of the hand, provided that there is no excessive tension in the finger flexor muscles or else with a closed fist. • Forward-horizontal direction movement of the arm with elbow flexion and more lateral movements require dissociation of pectoralis major from triceps. • A step-by-step modification of the voluntarily performed extensor synergy is essential.
  81. 81. • To bring the entire affected arm behind the body, participation of subscapularis along with dissociation of pectoralis major from elbow extensors is required. • Patient may initiate arm to rear of body using one of the either synergy. Alternatives are- – If standing balance is satisfactory, trunk rotation movements (movement not confined between chest and pelvis, but incorporating the hips), gradually increasing in range, with arms hanging lose by the side of the body. – Use of momentum while attempting to bring the arm backwards – Guidance and assistance may be required for some time before the patient succeeds in bringing the arm backward as a free movement.
  82. 82. • For bringing the arm forward to horizontal position and side-horizontal position requires adequate scapulothoracic movements and voluntary control over the upper extremity. • Guidance and assistance, isometric or eccentric prior to concentric activity and reversal of movement directions to gain control over movement combinations away from BLS. • Once the patient moves to stage IV or V, functional activities that are possible with those new muscle combinations to be stressed. • Functional activities will boost the patients motivation, improves coordination and control.
  83. 83. Training program for stage VI of upper limb • Not all patients can reach this level. • This stage- the influence of synergies is least on the movement combinations. • Lack of resistance to passive movements. • Individual joint movements are performed in the normal or near normal fashion. • A general tendency for the recovery of the hand to lag behind the rest of the affected upper limb.
  84. 84. • If the hand functions do not recover completely, the patient may feel those skilled movements performed by the affected hand as awkward and he may continue to use it as a secondary hand. • Motivate the patient to utilize his affected hand for most of the functional activities so that the coordination and control will improve and becomes comparable to the sound hand.
  85. 85. Training program for hand functions • The effectiveness of the hand to perform skillful activities is directly related to the function of entire upper extremity. • The restoration of hand function is predominantly a flexor phenomenon and progresses somewhat same way as normal restoration of hand function. • Aim: to promote mass grasp and mass release of objects. Later, more refined prehension. • Use of symmetrical associated reactions and imitation synkinesis to facilitate functional movements.
  86. 86. • If unable to initiate finger flexion on a voluntary basis, proximal traction response may help to achieve a mass grasp provided that he has some control of the proximal components of the flexor synergy. • Maintain the patient’s wrist in extension and a command like “squeeze the fingers” could be given. • Normally, a strong linkage exists between the muscles stabilizing the wrist in extension and fingers into flexion (following stroke, this linkage is usually disturbed, which should be re- established).
  87. 87. • Use of proprioceptive or exteroceptive stimulation over the proximal portion of the wrist extensors along with commands like “squeeze your fingers” may promote finger flexion with the wrist in extended position. • Later, gradually withdraw the support given to the wrist and commands like “hold your wrist” and “don’t drop it down” to be incorporated. Wrist extension is a component part of the extensor synergy. • Therefore, stabilizing the wrist in extension with the arm and the elbow in flexion is also essential.
  88. 88. • If the spasticity of the finger flexors is extensive, the affected hand’s thumb may be held flexed in the palm of the hand with other fingers close tightly over the thumb and makes release of the fingers impossible. • Brunnstrom has advised a series of manipulations, cutaneous stimulation, favorable body and arm postures to release the tension in the finger flexors and evoke background tension in the extensor muscles for preparation of voluntary finger extension.
  89. 89. • For instance, the therapist can sit face to face to the patient and then, she should pull out the patient’s thumb by gripping the base of it (around the muscles of the thenar eminence) with simultaneous passive supination of forearm. • If the tension in the flexors is marked, the wrist can be held in some degree of flexion. • Next, supinate and pronate the forearm slowly and repeatedly with cutaneous stimulation over the dorsum of the wrist and hand, when the forearm is in supination. This technique may help the hand to open partly or fully.
  90. 90. • Once background tension develops in the extensor muscles, the patient may actively participate in opening the hand with the forearm in the supinated position. • Even rolling of the fingers into flexion is believed to stretch the finger extensors which may elicit stretch reflexes, thus aiding in transfer of tension from flexors to extensors. • Souques’s position and friction over the ulnar aspect of the dorsum of the forearm with the arm supported may also encourage to relieve the tension within the finger flexors.
  91. 91. • Summation of voluntary effort with the above- mentioned reflex stimulation may result in active finger extension. • Once the extensor response of the digits is well established, the patient has to be requested to alternatively make the fist and open the fist with the arm gradually kept in lowered position. • Care has to be taken to avoid contact of the reflexogenic zone of the hand. • Indiscriminate use of a rubber ball in the affected hand given to strengthen the grip must be discouraged.
  92. 92. • Voluntary thumb movements frequently begin to appear when voluntary mass extension of the fingers becomes possible. • Enabling the movement of the thumb away from the contact of the index finger is utmost important for learning lateral prehension and advanced prehension for functional activities. • While moving the thumb away from the index finger, the patient should be requested not to generate excessive effort as it can flex the thumb and the other fingers.
  93. 93. • Application of friction or gentle local percussion over the tendons of abductor pollicis longus and the extensor pollicis brevis muscles near the wrist may abet thumb movements. • Depending on the severity of CVA, the restoration of hand function can halt at any stage and seldom recover completely. • Hemiplegic patients with sensory deficiency may find difficulty to maintain grip without conscious effort. • Similarly, presence of instinctive avoidance reaction or instinctive grasping reaction makes prehensile movements difficult or impossible and will continue till the influence of these reactions diminishes.
  94. 94. Gait Abnormalities and Gait Training for Hemiplegia • Restoration of safe standing and safe walking in a near normal pattern forms the key components of training procedure. • Gait patterns of patients with hemiplegia depends on the severity of the involvement and the manner of compensation the patient adopts. • Combination of muscles required for generating normal locomotion is not identical to the BLS.
  95. 95. • Challenging job for the therapist to find ways and means of modifying the gross movement synergies to bring about functional muscle combinations resembling normal human locomotion. • When comparing muscle action of hemiplegic patients with normal subjects there are considerable changes in phasic action of muscles. • Stance phase on the affected side - considerably shorter. • Swing phase - correspondingly longer.
  96. 96. • Knee extensors and the plantar flexors on the involved side are active throughout stance phase. • Poor performance of affected extremity necessitates, alters and intensifies muscle activity of the normal lower extremity. • Energy consumed by them for locomotion is considerably high with reduced speed and cadence. • Two main factors that cause locomotion difficulties in hemiplegia: – firm linkage of muscle groups in accordance with the dictum of primitive movements synergies – slowness of reactions of the muscle groups.
  97. 97. When BLS dominate the motor behavior, those muscle combinations essential for normal locomotion will be hindered. • Rapid rise and fall in muscle tension required for normal locomotion will not materialize in these patients. • While analyzing the gait, the behavior of the affected ankle, knee, and hip during the stance and swing phase have to be carefully studied. • Comparison of the muscle activities in the hemiplegic gait and normal gait is as follows:
  98. 98. Phase of gait Joint Motor behavior in normal subjects Motor behavior in hemiplegic side of patient Early stance phase At ankle joint During heel strike, the angle between foot and the leg is approximately 90° and as the weight is shifted to the forward foot, eccentric contraction of the pretibial muscles helps the sole to gradually and smoothly lower down to the ground. Activity of these muscles is also needed for stabilizing the ankle preventing sudden plantar flexion of the ankle. Dominance of BLS with anticipation of weight bearing on the involved lower limb frequently activates all the extensor synergy components. This prevents the normal association of the ankle dorsiflexors and the knee extensors essential for heel strike causing simultaneous contact of heel and forefoot to the ground. If the spasticity is marked, the toe may first come in contact with the ground.
  99. 99. Phase of gait Joint Motor behavior in normal subjects Motor behavior in hemiplegic side of patient Between early stance and midstance phase At Knee joint When heel strikes the ground, the knee is nearly extended. Immediately after the heel strike, a cushioning response consisting of initial flexion of short duration and small range precedes the knee extension. This flexion- extension response at the knee helps to keep the path of COG from rising and falling abruptly, aiding a smooth forward translatory motion of the body. During the flexion movement of the knee there is maximum activity of quadriceps muscle which prevents buckling of the knee and it ceases when the limb moves to midstance. If the limb is flaccid, attempts to support the body weight through the affected limb causes buckling of the knee. On the contrary, if the limb is spastic, mild to severe hyperextension of the knee may occur making the normal flexion-extension moment impossible. Hyperextension of the knee may also result from excessive tension in the plantar flexors which prevents a forward pivoting of the leg at the ankle which normally should happen during the locomotion.
  100. 100. Phase of gait Joint Motor behavior in normal subjects Motor behavior in hemiplegic side of patient Between early stance and midstance phase At Hip joint In these phases, activity of the hip abductors provides lateral stabilization of the pelvis which prevents the opposite side of the pelvis from dropping. Immediately after heel strike the hip extensors is found to show brief burst of activity which ceases soon before midstance. During weight bearing, dominance of extensor synergy components (including the hip adductors) causes failure of hip abductor muscles to respond, thus compromising lateral stability of the pelvis leading to a Trendelenburg limp (the pelvis of the normal side lowers when the affected side weight bears) which will not be obvious if the patient uses a cane or external support. Patient may incline his trunk laterally to advance forwards.
  101. 101. Phase of gait Joint Motor behavior in normal subjects Motor behavior in hemiplegic side of patient Midstance phase At ankle Once the metatarsal heads contact the ground, the activity of dorsiflexors reduces. During this phase, the leg pivots forward about the ankle joint causing reduction of the angle between the foot and the leg. A gradual and eccentric contraction of the calf muscles begins when the body weight advances in front of the ankle joint preventing excessive pivoting of the leg at the ankle. Attempt to advance the body weight in front of the ankle joint increases the tension within spastic calf muscles preventing forward pivoting motion of the leg at the ankle joint. As a result, the patient will find difficulty in advancing the normal foot to proper distance making the stride length unequal and the swing phase too rapid. If the tension within the calf muscles is marked, the involved limb may lead all along with drawing of the normal foot up to, but not beyond the affected one.
  102. 102. Phase of gait Joint Motor behavior in normal subjects Motor behavior in hemiplegic side of patient Late stance phase At ankle This phase is characterized by rising of the heel from the ground with simultaneous flexion of the knee in order to prepare the limb for forward swing. In this phase, concentric activity of the plantar flexors occurs and it increases for generating an effective “push-off”. Activity of the plantar flexors brings the foot into 20° plantar flexion. Thus the “push-off” produced by the calf muscles activity along with inactivity of the knee extensors, activity of other muscles and the gravitational forces are responsible for initiating the forward swing of the limb. Tension within the quadriceps persists in this phase and prevents the knee from flexing. As a result the combination necessary for push-off and initiation of the swing phase will not materialize. Therefore, the patient has to rely on compensatory methods such as external rotation and adduction or circumduction or excessive hip hiking in order to bring the limb forward.
  103. 103. Phase of gait Joint Motor behavior in normal subjects Motor behavior in hemiplegic side of patient Late stance phase At knee joint In this phase, the inhibition of the quadriceps muscles activity enables the knee to flex in order to initiate the forward swing of the limb. The strong bond existing between the calf muscles and the quadriceps muscles does not allow the muscle combination required for initiation of the forward swing of the limb. Late stance phase At hip joint To prepare the limb for forward swing, there will be flexion of the hip. The flexion of hip accompanies the flexion of the knee and plantar flexion of ankle. Activity of the superficial hip flexors is responsible for initiating it. Normal combination required for preparation for forward swing will be difficult or impossible due to the dominance of the BLS. Lack of hip flexion and knee flexion along with persistence of calf muscles activity prevents effective push-off.
  104. 104. Phase of gait Joint Motor behavior in normal Motor behavior in hemiplegic side Swing phase At ankle joint Slight activity of pretibial muscles through out this phase prevents the foot from dropping down. Dominance of the extensor synergy components prevents the activity of dorsiflexors causing talipes equinus and insufficient ground clearance. The ankle may also invert markedly making the gait unsafe for the patient. The patient may utilize the flexor synergy components in an exaggerated manner to dorsiflex the ankle for clearing the ground.
  105. 105. Phase of gait Joint Motor behavior in normal Motor behavior in hemiplegic side Swing phase At knee joint Muscular and gravitational forces bring about the forward acceleration of the limb. Most of swing phase, the muscular activity is minimal and inertia is responsible for forward motion. Persistence of extensor synergy until the late stance phase makes the knee stiff. In such situations, the patient may often use the total flexor synergy for flexing the knee joint and frequently the onset of knee flexion is delayed due to poor push-off. Therefore, the involved side knee will be lifted forward and upward with leg hanging more or less vertical and foot well above the ground, as if the patient is stepping over an obstacle.
  106. 106. Phase of gait Joint Motor behavior in normal Motor behavior in hemiplegic side Swing Phase At hip joint If extensor synergy dominates, the normal shortening of the limb essential for swing through will not materialize. In such circumstances, the patient may circumduct or hike the pelvis to clear the ground. If the hip is held stiff, he may tilt the pelvis backward and use the abdominal musculature and the gait will resemble that of ankylosed hip. The patient may also use the total flexor synergy for flexing the hip joint as mentioned earlier. If the motor control is poor, the patient may use the hip adductors to drag the affected limb forwards. In such situations, the patient will never advance his affected limb beyond the normal foot and the pelvis will stay behind the affected side with the hip held in external rotation and foot in eversion.
  107. 107. Gait Training • During the flaccid and later in spastic stages these patients may use one or other forms of compensation and may become good or fair walkers. Compensations are characterized by poor gait pattern which is stubbornly resistant to correction. • To avoid such compensatory strategies, right from the early days, concentrate on preparation for walking while postponing actual gait keeping in mind that our aims are to restore safe standing and a safe gait as normal as possible.
  108. 108. • However, in most severely involved patients, when chances to progress beyond the synergy stages appear slim, a compromise has to be reached and our objective should be to make them modestly ambulant. For such patients, BLS may help to to overcome the problem of ambulation. • Preparation for gait should commence from the early period (Weight bearing exercises and trunk balance in sitting and standing).
  109. 109. • Components necessary for normal gait – Modification of motor response to obtain muscle associations resembling those required for normal gait. – Reversal of movement direction and – Strengthening the weak muscles • Treatment should follow a stepwise series of activities with increasing complexity, progressing from the least demanding position (supine) to the most demanding position (standing).
  110. 110. Training procedures to improve gait: • Dominance of synergies may make the severely involved patients unable to restore their normal gait. • In minimally involved, modification of motor responses may not be necessary as the synergies lose their dominance leading to spontaneous return of normal/near normal gait. • Many of the patients who falls between these extremes require modification of motor responses to attain a near normal gait. • Training should consist of techniques to strengthen weak components of flexor synergy.
  111. 111. • To facilitate hip flexion control bilateral contraction followed by unilateral contraction of affected side hip flexors can be attempted. For instance, – inclining the trunk backwards and forwards when the patient sits on a chair, produces a lengthening contraction and shortening contraction of hip flexors respectively. Trunk inclination movements also activate the abdominal muscles. Commands like “hold” when the patient inclines forwards will promote isometric contraction of hip flexors. • If no control over hip flexion: Marie Foix reflex or Bechterev’s reflex (quick passive plantar flexion of the toes in supine position with hip and knee in slight flexion) to a total flexion response.
  112. 112. • Later, voluntary effort should be superimposed on reflexive stimulation, followed by training activation of dorsiflexors in combination with hip and knee extension. • To generate a better motor control, attempts should be made to initiate ankle dorsiflexion movement without reflex assistance.
  113. 113. Predominance of extensor synergy No normal association of hip abduction with hip and knee extension Trendelenburg limp (common in many hemiplegic patients).
  114. 114. • Attempts to activate hip abductors and associate it with hip and knee extension. • Can be achieved by reflexive elicitation of hip abductor - use of Raimiste’s hip abduction phenomenon in supine, use of local facilitatory techniques, superimposition of voluntary effort on the reflex contraction by commands like “spread your legs” and promotion of isometric contraction of hip abductors in side-lying for gaining better control over the hip abductors.
  115. 115. • Later, attempts should be made to abduct the affected limb. E.g. side kicking movement in standing. • Hiking or elevating the pelvis of the sound side also necessitates a strong contraction of the hip abductor muscles of the affected side. • If the methods of activation of hip abductors is successful, then commands like grow tall on each step can be incorporated to generate smooth walking pattern with a suitable cadence dictated. • If elimination of Trendelenburg limp is difficult, use of a cane can be encouraged.
  116. 116. • If the ankle dorsiflexion response is poor: manual resistance to hip flexion movement and local facilitatory techniques can be tried. • Attempts to promote voluntarily dorsiflexion of the ankle while sitting on a higher chair (later even in standing posture should be attempted). • Even facilitation of eversion of the subtalar joint along with dorsiflexion of the ankle is essential to activate the peroneal muscles which lies idle.
  117. 117. • Activation of evertors prevent abnormal association of inversion along with dorsiflexion of the ankle. • Use of stretch reflex, percussion or exteroceptive stimulation over the evertor muscles and efforts to isometrically contract the muscle may promote better motor control of the ankle and subtalar joint. • For smooth locomotion : Reversal of direction to promote alternating knee flexion and extension movement. (training indicated in supine, side lying, sitting and standing positions).
  118. 118. • For weak knee flexors: Associated reactions, use of exteroceptive stimulation over the hamstring muscles may induce knee flexion, if not, use of side lying position may eliminate the influence of gravitational force and minimize the effect of TLR. • Training the patient to slide the foot on the floor while sitting on a chair helps to guide and provide sensation of isolated knee flexion motion. • Sitting on tall chairs and sliding the foot back and forth underneath the chair enables further development of reciprocal knee flexion and extension.
  119. 119. • To promote heel strike and push-off in gait, reciprocal ankle dorsiflexion with knee extension, and ankle plantar flexion with knee flexion (in forward lean position). Later, the position should be gradually modified to a standing. • In spite of increased tension within the quadriceps, affected knee may buckle and cause a fall or hyperextension of the knee. Partial squat with even weight bearing, weight shifts and lifting of the sound leg and later involved leg of the ground may improve the knee stability & minimize buckling /hyperextension.
  120. 120. • Spasticity and dominance of BLS determine the full return of normal arm swing, rotation and counter rotation of the pelvis and trunk. Appropriate training to promote arm swing along with trunk rotation. • For instance while standing, rotation of the trunk slowly to either side with the patient asked to wrap his arms. Later, when he learns to voluntarily wrap his arms, attempts to walk with exaggerated trunk rotation can be incorporated. However, care should be taken to maintain the rhythm, even if the trunk and arm movements are not perfect.