1. MANUAL THERAPY TECHNIQUES
USED IN NEUROLOGICAL CONDITIONS.
Presenter: Sana Rai (MPT 1st Year )
Guide: Dr. Suvarna Ganvir (PhD)
Department of Neurophysiotherapy
D.V.V.P.F’s College of Physiotherapy, Ahmednagar
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2. Objectives
 Introduction
 Types of approaches used in neurological condition.
1. Neurodevelopmental Technique (Bobath Approach)
2. Roods Approach
3. Brunnstrom’s Approach
4. Proprioception Neuromuscular Facilitation(PNF)
 Recent Advances
 Summary
 References
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3. Introduction
 To treat patients with neuromuscular disease,
selection of appropriate treatment approach is
essential.
 Clinical signs and symptoms are the best indicators
for selecting an approach or a combination of
approaches.
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4.  In some patients with additional system involvement
might force to modify the treatment approach.
 Duration and frequency of the selected approach
depends on the severity and the present functional
level of the patient.
 Quantify the effect of this approach on functional
recovery in patients.
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5. Neurodevelopmental
Treatment (NDT)
Bobath Approach
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6.  Karel Bobath & Berta Bobath developed treatment
designed to increase normal movement patterns in
children with cerebral palsy & adult with acquired
hemiplegia.
 Their treatment focuses on restoring normal
movements & eliminating abnormal movements.
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7. Principles of NDT
1. Interactive process
2. Active participation
3. Normalize the tone
4. Appreciation of normal movt
5. Functional activity
6. Task /environment modification
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8. 1. Interactive Process
 Interactive process between individual, task and
environment.
 Eg. Picking up an object from a desk by affected
hand
 Explain task to the pt, give an idea about the
environment
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9. 2. Active Participation
 Instead of therapist passively doing movements
 Ensure pt’s motivation and participation
 Give feedback
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10. 3. Normalize the Tone
 One cannot impose normal movements on abnormal
tone
 Weight bearing on affected side
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11. 4. Appreciation of Normal Movt
 Normal movement is learned by experiencing what a
normal movement feels like.
- Sensory feedback
- Vision
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12. 5. Functional Activity
 Preparation incorporated into functional activity
( promote carry-over.)
 Teaching postural control
 Eg. sit to stand
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13. 6. Task /Environment Modification
 Picking up object from the desk
 Modify task- break into components
 Modify environment – use ball, other unstable
surface
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14. Clinical Implication
1. Weight bearing on the affected side:
 Most effective way to normalizing tone.
 Low tone- facilitative and high tone- inhibitory.
 Also provide sensory input to the hemiplegic side
through proprioception.
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15. 15

16. Comparison of Bobath based and movement
science based treatment for stroke: a
randomised controlled trial.
P M van Vliet 2005
• Conclusions: There were no significant differences in
movement abilities or functional independence between patients
receiving a BB or an MSB intervention.
• Therefore the study did not show that one approach was more
effective than the other in the treatment of stroke patients
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17. Roods Approach
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18.  Given by Margaret S. Rood in the year 1950
 Appropriate sensory stimulation can elicit specific
motor responses.
 Muscle action could be “activated, facilitated and
inhibited through the sensory system.
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19. Principles of Treatment
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20. 1. TNR and TLR can assist or retard the effects of
sensory stimulation.
 Tonic neck receptors lie in the muscles and skin of the
neck region and response to change in the relationship of
head to the neck.
 The labyrinthine receptors lie in the ampullae of the
semicircular canals and in the vestibule.
 These receptors are affected by the position of the head in
relation to gravity.
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21. 2. Stimulation of specific receptors produce three
major reactions.
 The three major reactions that can be produced by
stimulation of specific receptors are
1. homeostatic responses via the autonomic nervous
system,
2. reflexive protective responses via spinal and brain stem
circuits and
3. adaptive response that require greater integration of all
regions of the nervous system.
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22. 3. Muscles have different duties.
 Heavy work muscle should be integrated before light
work muscles.
 The light work muscles (mobilizers) are primarily
flexors and adductors used for the skilled movement
patterns.
 The heavy work muscles (stabilizers) are primarily
extensors and abductors used for postural support.
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23. Facilitation techniques: Inhibition technique:
 Light moving touch
 Fast brushing
 Icing
 Heavy joint compression
 Stretch
 Resistance
 Neutral warmth
 Gentle shaking or rocking
 Slow stroking
 Slow rolling
 Light joint compression
Clinical Implication
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24. Icing:
 It is used for facilitation of muscle activity and
autonomic nervous system responses.
 It is used for patients who exhibit hypotonia and are
in a state of relaxation.
 It activate the more myelinated A delta fibers causing
reflex withdrawal response in the superficial muscles.
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25. 25
Journey of a child with spastic diplegic
cerebral palsy from doldrums to hope.
Divya Midha (2015) case report
• Conclusion: With the application of various therapeutic
techniques such as Roods approach, sensory integration, and static
weight bearing therapies, an improvement was brought (GMFCS
Level V-IV) in the gross motor functions as well as the child's
social skills.
• Child may also become less irritable on tactile stimulation to his
body.

26. Brunnstrom’s Approach
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27.  Developed by Signe Brunnstrom, a physical therapist
from Sweden.
 Emphasize on the development of synergy in spastic
group of muscles.
 This approach encourages development of flexor
and extensor synergies during early recovery, with
the intention that synergic activation of muscles will,
with training, transition into voluntary activation of
movements.
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28. Principles of Treatment
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.
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29. 3.Proprioceptive and exteroceptive stimuli assist in
eliciting the synergies.
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.
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30. 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.
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31. Clinical Implication
1. Trunk balance in sitting :
 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.
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33. 33
Comparison of Brunnstrom movement therapy and
Motor Relearning Program in rehabilitation of
post-stroke hemiparetic hand: a randomized trial.
Shanta Pandian et al 2012
•BHM was found to be more effective than MRP in
rehabilitation of the hand in chronic post-stroke patients.
• MRP protocol comprises the use of the entire upper extremities
along with the hand rather than the specific hand or finger
movements in BHM

34. Proprioception Neuromuscular
Facilitation (PNF)
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35.  Technique of PNF are method of placing demands in
order to secure a desired response.
 Motor function can be improved using proprioceptive
neuromuscular facilitation (PNF), and approach
initially developed by Dr. Herman kabat and Maggie
knott.
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36. Principles of PNF
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37. 1. All human beings have potentials that are not fully
developed.
 The normal person has a vast and untapped neuromuscular
potential, which may be developed through environmental
influences and voluntary decisions or tapped during
stressful episodes.
 Based on this philosophy, the therapist always strives to
treat function, motivate the patient to achieve higher
levels, and uses the patient’s strengths to minimize his or
her weaknesses. 37

38. 2. Normal motor development proceeds in a cervocaudal
and proximo distal direction.
 Motion develops from proximal points to distal points.
 During treatment, the head and neck are treated first because
they influence the movement pattern of the body.
 Next, the trunk is treated, because it provides the foundation
of function.
 After adequate control of the head, neck, and trunk is
established, fine motor skills may be developed.
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39. 3. Early motor behavior is dominated by reflex activity.
Mature motor behavior is reinforced or supported by
postural reflex mechanisms.
 During treatment, reflexes may be facilitated to support
weak muscles by choosing a specific developmental
posture, initiating part of a
 functional activity or pattern, or involving the head and
trunk with extremity patterns.
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40. 4. The growth of motor behavior has cyclic trends as
evidenced by shifts between flexors and extensor
dominance.
 During functional activity, movements alternate between
flexion and extension.
 This reciprocal relationship leads to stability and balance
of postures.
 In treatment, the reciprocal relationship of flexors and
extensors may be facilitated to re-establish stability and
balance.
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41. 5.Goal-directed activity is made up of reversing
movements
 Normal movements are rhythmic and reversing.
 Reversing movements establish an equilibrium among
activities and establish a balance and interaction between
antagonists.
 Treatment must facilitate movement in both directions to
enhance functioning.
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42. 6. Normal movement and posture depend on “synergism”
and a balanced interaction of antagonists.
 Functional movement relies on a balance of reflex activity,
flexor-extensor dominance, and reversing movements.
 During treatment, imbalances among these factors are
corrected to restore normal patterns of motion and
postural responses.
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43. 7. Developing motor behavior is expressed in an orderly
sequence of total patterns of movement and posture.
 Motor behavior develops in a specific sequence.
 Combined movements of the neck, trunk, and
extremities also progress in a specified sequence.
 Treatment must progress in a similar fashion
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44. 8. Normal motor development has an orderly sequence
but lacks a step-by-step quality (overlapping results).
 Although development of motor behavior is
sequential, one activity is not perfected before
another more advanced activity is initiated;
overlapping occurs.
 In treatment, this overlapping may be used to
facilitate progress.
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45. 9. Improvement of motor ability depends on motor
learning.
 Motor learning is enhanced through the use of
multisensory inputs.
 Auditory, visual, and tactile stimuli are used to progress
learning.
 Treatment that uses these multisensory inputs may
optimize learning opportunities, thereby maximizing the
patient’s progress toward more complete functional
ability.
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46. 10. Frequency of stimulation and repetition of activity
are used to promote and retain motor learning and for
the development of strength and endurance.
 The motor learning process requires repetition or
practice of the task to be learned.
 In this way, learning is enhanced through repetitive
tasks, and through a repetitive therapeutic exercise
program.
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47. 11. Goal-directed activities coupled with techniques of
facilitation are used to hasten learning of total
patterns of walking and self-care activities.
 Realistic functional goals are continually set for the
patient throughout treatment.
 Activities that have meaning for the patient are more
effectively integrated into motor learning.
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48. Clinical Implications
 In patient with Parkinsonism strengthening the
patient’s weak, elongated extensors muscles while
ranging the shortened, tight flexor muscles.
 In upper extremities, bilateral symmetrical D2
flexion patterns are ideal to counteract kyphosis.
 while for lower extremities D1 extension pattern to
counteract the typical flexed, adducted position
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49. 49
Proprioceptive NeuromuscularFacilitation (PNF):
Its Mechanisms and Effects on Range of Motion and
MuscularFunction.
Kayla B. Hindle et al (2012)
Research indicates that PNF stretching, both the CR and CRAC
methods, are effective in improving and maintaining ROM, increasing
muscular strength and power, and increasing performance, especially
after exercise. However, proper protocol and consistency must be
followed to attain and maintain the benefits of PNF techniques.

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Perspective of Neuro Therapeutic
Approaches Preferred for Stroke
Rehabilitation by Physiotherapists
Gajanan Bhalerao (2016)
• Conclusion: 96% of therapists are well aware of neuro approaches, but face
difficulty practicing them.
•PNF and CIMT are most commonly preferred and practiced approaches,
followed by NDT , Brunnstorm, Roods and MRP.
• This study suggests that the physiotherapists are still practicing more of
traditionalapproachesthan task specific approachessuch as CIMT and MRP.
• The study further shows that majority of the therapists i.e.87% have not had
any additional training and that 90% are keep on acquiring additional
knowledge about these approachesthrough some workshop or a seminar.

51. Summary
 Introduction
 Types of approaches used in neurological condition.
1. Neurodevelopmental Technique (Bobath Approach)
2. Roods Approach
3. Brunnstrom’s Approach
4. Proprioception Neuromuscular Facilitation(PNF)
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52. References
 Manual TherapyApproachesIn NeurophysiotherapyBy: Suvarna Ganvir
and Shyam Ganvir.
 Physical Rehabilitation5th Edition By Susan B.O’Sullivan.
 Van Vliet PM, Lincoln NB, Foxall A. Comparison of Bobath based and
movement science based treatment for stroke: a randomised controlled
trial. Journal of Neurology, Neurosurgery & Psychiatry. 2005 Apr
1;76(4):503-8.
 Midha D, Uttam M, Neb M. Journey of a child with spastic diplegic
cerebral palsy from doldrums to hope. Indian Journal of Cerebral Palsy.
2015 Jul 1;1(2):127.
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53.  Pandian S, Arya KN, Davidson ER. Comparison of Brunnstrom movement
therapy and Motor Relearning Program in rehabilitation of post-stroke
hemiparetic hand: a randomized trial. Journal of bodywork and movement
therapies. 2012 Jul 1;16(3):330-7.
 Hindle K, Whitcomb T, Briggs W, Hong J. Proprioceptive neuromuscular
facilitation (PNF): Its mechanisms and effects on range of motion and
muscular function. Journal of human kinetics. 2012 Mar 1;31:105-13.
 Bhalerao G, Shah H, Bedekar N, Dabadghav R, Shyam A. Perspective of
Neuro Therapeutic Approaches Preferred for Stroke Rehabilitation by
Physiotherapists. Indian Journal of Physiotherapy and Occupational
Therapy-An International Journal.2016 Jan;10(1):47-50.
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