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1

Brunnstrom’s Approach to Exam and
Intervention

• Areas of examination:

• Sensory function (passive motion sense of UE/LE, finger recognition, sole sensation, light touch, and temperature)
• PROM
• Postural reflexes
• Recovery stages

2

Brunnstrom’s Approach to Exam and
Intervention

• Principles of Intervention:

• Creating movement by stimulating abnormal reflexes would carry-over into
normal patterns of movement

3

Post CVA
Which movement happens first in UE

Flexion

4

Brunnstrom’s Stages of Recovery***

• Stage 1: Flaccidity, no movement
• Stage 2: Minimal voluntary movement, associated reactions; spasticity begins
to develop
• Stage 3: Voluntary control of movement synergies; spasticity peaks in
severity
• Stage 4: Mastery of some movement combo outside of the synergies;
spasticity begins to decline
• Stage 5: Difficult movement combo are learned; synergies lose their
dominance
• Stage 6: Spasticity disappears, isolated joint movement & coordination
achieved
• Stage 7: Normal movement

5

Stages of Recovery:
Can stages be revisited or skipped?

NO

6

Stages of Recovery:
Patients progression

• Patients may plateau at any
stage

• Hemiplegic UE and LE may be in
different stages

• No set amount of time for each
stage

• Faster progress thru stages, more
functional

7

Stage 1:
When does it happen?
How is movement like?
Motor tests:
For shoulder and elbow?
For hand?
For lower limb and trunk?

immediately following the acute episode, flaccidity of the
affected limbs is present, and no movement (either reflexive or
voluntary) can be initiated
- Shoulder and elbow: flaccidity during AROM/PROM and spasticity
testing
- Hand: flaccidity during AROM/PROM and spasticity testing
- Lower limb and trunk: flaccidity during AROM/PROM and spasticity
testing

8

Stage 2:

How is movement like?
Motor tests:
For shoulder and elbow?
For hand?
For lower limb and trunk?

minimal voluntary movements and/or associated reactions may appear. The basic limb synergies appear; flexor synergy in the UE and extensor synergy in the LE occur first. Spasticity begins to develop
- Shoulder and elbow: Observe flexor synergy. Test spasticity with
MAS (score 1 or 1+)
- Hand: little or no active finger flexion
- LE and trunk: minimal voluntary movements of the LE. Observe
extensor synergy in supine position. Test spasticity with MAS (score
1 or 1+).

9

Synergy - Abnormal synergies

• Movement is bound together
• Stereotyped
• Primitive/Reflexive/Automatic
• Limited combinations of movement
• Muscles are bound together in UNITS of motion

10

UE Flexor Synergy Pattern***

- Flexion of the elbow to an acute
angle
- Full range supination of the forearm
(sometimes pronation occurs)
- Abduction of the shoulder to 90
degrees
- External rotation of the shoulder
- Retraction and/or elevation of the
shoulder girdle

11

LE Extensor Synergy Pattern***

- Plantar flexion of the toes
(inconsistent, big toe may be
extended)
- Plantar flexion and inversion of the
ankle
- Extension of the knee
- Extension of the hip
- Adduction and internal rotation of
the hip

12

Synergies

• Antagonist muscles to dominant components are:

• Weaker
• More difficult to elicit

• i.e. Biceps (elbow flexion) is dominant thus Triceps (elbow
extension and antagonist ) are weak.

13

UE Extension Synergy

Shoulder girdle Depression and protraction
Shoulder Adduction and internal rotation
Elbow Extension
Forearm Pronation
Wrist Extension
Fingers Flexion

14

LE Extension Synergy

Hip
- Extension
- Adduction
- Internal Rotation

Knee Extension

Foot/Ankle Plantarflexion Inversion

15

LE Flexion Synergy

Hip

Flexion
Abduction External
rotation

Knee Flexion (to 90 deg)

Foot/Ankle Dorsiflexion Inversion

16

Stage 3: What happen to the synergies and spasticity***
Motor tests:
- Shoulder and elbow:
- Hand:
- LE and trunk:

Stage 3: Synergies become dominant, spasticity reaches its peak***
- Shoulder and elbow: Observe basic limb synergies, grade synergy based on
the active range of motion of each joint involved (25% is 1 point, 50% is 2
points, 75% is 3 points, 4 is full AROM at the joint)
- Hand: mass grasp; no voluntary finger extension; possibly reflexive
extension of fingers
- Mass grasp: proximal traction response. Maintain wrist in extension;
therapist supports arm and elbow. Command pt to squeeze

- LE and trunk: synergies dominant; some non-stereotypical voluntary
movements occur
- Observe hip-knee-ankle flexion in sitting and standing

17

Stage 4: What happen to the synergies and spasticity***
Motor tests:
- Shoulder and elbow:
- Hand:
- LE and trunk:

In addition to synergies some additional voluntary movements
appear. Spasticity declines
- Shoulder and elbow: spasticity declines, some non-stereotypical
voluntary movements occur (placing the hand behind the body,

elevation of the arm to forward-horizontal position, pronation-
supination with elbow at 90 degrees)

- Hand: lateral prehension; semi-voluntary finger extension
- LE and Trunk: gain more control over individual joints. Sitting, knee
flexion beyond 90 degrees with the foot sliding backward on the
floor. Voluntary DF of the ankle w/o lifting the foot off the floor

18

Stage 5: What happen to the synergies and spasticity***
Motor tests:
- Shoulder and elbow:
- Hand:
- LE and trunk:

More complicated voluntary movements appear, synergies no longer
dominate, spasticity continues to decline

- Shoulder and elbow: relative independent from synergies.
- Arm raising to a side-horizontal
- Arm raising forward and overhead
- pronation-supination with elbow extended

- Hand: palmar prehension; possibly cylindrical and spherical grasps;
voluntary mass extension of fingers, variable range

- LE and Trunk: Standing, isolated non-weight bearing knee flexion, hip
extended or nearly extended; standing, isolated ankle DF with knee
extended and heel forward in position of short step

19

Stage 6: What happen to the spasticity***
Motor tests:
- Shoulder and elbow:
- Hand:
- LE and trunk:

Individual joint movements become possible, coordination
approaches normal, spasticity disappears except when the pt is under
stress or sick
- Shoulder and Elbow: isolated joint movements are freely performed
- Hand: All prehension types under control; full range voluntary
extension of fingers; individual finger movements present, less
accurate than on opposite side
- LE and Trunk: Standing, hip abduction beyond range obtained from
elevation of the pelvis.

20

Stage 6 additional tests:
Speed tests, UE:

- The hand is moved from lap to
chin, requiring complete range
of flexion of the elbow
- the hand is moved from lap to
opposite knee, requiring full
range of extension of the elbow

21

Stage 6 additional tests:
Speed tests, hand:

- Wrist flexion/extension, fist
closed
- Wrist circumduction
- Individual thumb movements
- Individual finger movements

22

Associated Reactions***:
What are they?

VOLUNTARY forceful movements in other parts of the body elicit similar
movements in the affected limbs
• Abnormal synergy
• The reflex contraction of muscle, that may include involuntary
limb movement

23

Associated Reactions***:
When they can present?
How to evoke a response?

• May be present years after initial onset of hemiplegia

• Repeated stimulation may be required to evoke a response

24

Associated Reactions***:
What it does and does not show?

• Does NOT show you the patient’s ability to voluntarily move

• Does show you there is a way to initiate movement.

25

Associated Reactions***:
What does Brunnstrom say about it

• We can use the tone/movement created by these abnormal reflexes
to facilitate movements in an otherwise flaccid extremity

26

Associated Reactions***:
Found mostly in patients with...
When are they most pronounced?

Commonly elicited when spasticity is present
• However occasionally found in pts with little to no spasticity

• More pronounced when moving against resistance

27

UE Associated Reactions

Flexion = Flexion

Extension = Extension

28

LE Associated Reactions

Flexion = Extension

Extension = Flexion

29

Homolateral limb Synkinesis
What is it?
How does the UE/LE move?
Occurs in patients with?

• Movement of affected UE/LE elicits movement of other extremity of
affected side in the same direction at the same time

• Both UE/LE move into flexion or extension direction

• Occurs in patients with spastic hemiplegia

30

Associated Reactions - TREATMENT

• Raimiste’s Phenomenon

Abd or add of the unaffected LE (just hip) results in the same motion of the affected LE

31

Associated Reactions - TREATMENT

• Raimiste’-like Phenomenon

Abd or add of the unaffected UE results in the same motion of the affected UE

32

Associated Reactions - TREATMENT

• Souques' Phenomenon

Reflex finger extension when the affected arm is passively flexed past 90° of shoulder
flexion

33

Associated Reactions

• Rowing Patterns: what is it and what to do with the patient

• Another form of an associated
reaction

• Capitalize on bilateral
symmetrical activity

• Ask patient to pull back with
non-involved arm
• Hope to see involved arm move
as well
• Use of thumb grip or “shake
hands” with patient

34

Postural Reflexes
• Present during

• Become integrated during

• Can reappear after

• Present during normal development

• Become integrated during infancy/youth

• Can reappear after damage to brain

35

Abnormal Postural Reflexes

Think as SAATT like a posture "sat"

• Symmetrical Tonic Neck Reflex (STNR)

• Asymmetrical Tonic Neck Reflex (ATNR)

• Tonic Labyrinthine Reflex (TLR)

• Asymmetrical Tonic Labyrinthine Reflex (ATLR)

• Tonic Lumbar Reflex

36

STNR (Symmetrical Tonic Neck Reflex)

"seal stretch posture"
• Neck flexion results in
• UE Flexion
• LE Extension

• Neck extension results in
• UE Extension
• LE Flexion

37

ATNR (Asymmetrical Tonic Neck Reflex)

"Mr. Olympia posture"
• Neck rotation (or lateral flexion) results in

• Flexion of the “skull” limbs

• Extension of the “jaw” limbs

38

Tonic Labyrinthine Reflex*

"like a ragdoll"

• Head position in space

• Supine*
• Maximal extension

• Prone*
• Minimal extension

39

ATLR (Asymmetrical Tonic Labyrinthine
Reflex)

• Head position in side-lying facilitates

• Ceiling side
• UE and LE flexion

• Floor side
• UE and LE Extension

40

Tonic Lumbar Reflex
What is it and what posture is it similar to?

• Receptors in lumbar spine

• Trunk Rotation Facilitates:

• Extension UE and Flexion LE
• Opposite side

• Flexion UE and Extension LE
• Same side

• Tennis Serve:
• Body is right rotated
• RUE (elbow) flexion, RLE (hip)
extension
• LUE extension, LLE flexion

41

Postural Reflexes

• Any or all of these reflexes may become grossly exaggerated in the
presence of

CVA/TBI

• As compared to normal subjects.

42

Postural Reflexes

• Latency Period:

interval period between onset of stimulus and onset
of response

43

Postural Reflexes

• Summation effect:

how you set a patient up can either increase or
decrease a given response
• .i.e. with supine with neck flexion will increase LE extensor response (STNR)
but we often ask for hip/knee flexion in this position and then wonder why it
is so difficult for the patient.

44

Use of postural reflexes

• For reinforcing treatment/particular movement
• To create and set up background tension for movement.

Gradually wean patient from influence of reflexes
• i.e. working on elbow extension

45

Use of ATNR*

• Head turned to side looking for extension
• Head in neutral
• Head to opposite side looking for elbow extension

46

Marie-Foix Reflex
What is it and what is it not?

• NOT a postural reflex
• Quick movement into
plantarflexion and inversion
causes a reflex dorsiflexion at the
ankle and flexion of the hip

47

Clinical Application of the Stages

• OVERALL our job is

• To help the patient progress thru the recovery process

• To facilitate as normal and functional movement as possible

48

Breaking out of Synergy:
What do do and what do do when providing resistance

• Quick stretch to facilitate response
• Manual contact for guidance
• Resistance may be used to reinforce a response

• Elicit overflow
• Proximal to distal
• Stronger to weaker

49

When Breaking Synergy:
What should you do

• Contraction Type
• Isometric
• Eccentric
• Isotonic

• Easier for Pt with CVA to hold a contraction/position than to have to
move it.

50

Long Term Goals of Synergy Treatment

• To try and get patient out of abnormal synergy pattern into something
more desirable
OR
• To change it to make it more functional.

51

Treatment Example

Facilitating trunk control

- In sitting, hold affected
elbow
- Actively shift weight
and facilitate trunk
forward and obliquely
forward

52

Stroke Rehabilitation Assessment of
Movement (STREAM)

Outcomes Measure to assess recovery of movements after stroke
- Incorporates movements from the Brunnstrom’s recovery stages
Includes:
- Voluntary Movement of the limbs (20 pts for UE, 20 pts for LE)
- Basic Mobility (30 pts)
- Max score 70; higher score indicates more normal movement

53

What is NDT?
What is the goal?
Used primarily with? (2)

The Bobath Approach
• A therapeutic approach to the assessment and management of dysfunction in people with neurological impairments
• The ultimate goal: To maximize the person’s functional ability.
• Developed to be used primarily with:
• Children who have cerebral palsy (CP)
• Adults with cerebral vascular accidents (CVA)

54

Goals of NDT

• Provide patient with the sensation of normal movement by inhibiting
abnormal postural reflex activity

55

Key Elements to NDT

• Alignment
• Handling
• Placing
• Practice

56

Key Elements to NDT - ALIGNMENT

Postural Control

• Maintain alignment ex:correct sitting alignment
• For the functional task
• Vertical relationship between
body segments to oppose gravity
• Create a stable reference frame
for extremities & head.

57

Key Elements to NDT - HANDLING***
What is it?

A process in which a therapist puts
his/her hands on a patient in a
specific region (key point of
control) to facilitate a targeted
movement

58

Key Elements to NDT - HANDLING***
Observation:

• Observation:
• Use your eyes to scan the whole
person
• Your eyes will also help you to
communicate with the patient, so
you need to arrange yourself as a
handler to give and take feedback
visually

• YOUR EYES NEVER NEED TO BE
WHERE YOUR HANDS ARE.

59

Key Elements to NDT - HANDLING***
• Where do you place your hands?
• Handle through:
Key points?

Dependent on desired movement
outcome
• Offers patient feedback and
element of control.

• Handle through:
• Muscle: in correct synergies
• Bone - to maintain better
alignment or disallow movements
extraneous to the desired
movement outcome.

• The choices you make here are
directly related to your patient's
problems, tendencies in
movement as based on those
problems.
• The key points that you choose
should make movement easier!

60

Key Elements to NDT - HANDLING***
Open Handed Approach

• Cover greater amount of body
surface
• NO Grasping
• Elicits counter resistance
Move Slowly!

61

Key Elements to NDT - HANDLING***
Soft Hands

• Less noxious input
• Build input gradually
• More natural output
• Using
• skin receptors for facilitation or
inhibition
• Joint receptors (approximation)
Move Slowly!

62

Key Elements to NDT - HANDLING***
When to use manual cues and do not...

• Only use manual cues if visual, verbal and all other forms of input are
not working or are not enough!

• Do not overuse manual cues!!!!

63

Key Elements to NDT - HANDLING***
Inhibition

• A technique utilized to decrease
excessive tone and movement.
- Restore normal alignment in the
trunk and extremities by
lengthening spastic muscles
• Stop unwanted movements and
associated reactions from occurring
• Teach methods for decreasing the
abnormal posturing of the arm and
leg during task performance.

64

Key Elements to NDT - HANDLING***
Facilitation

• A technique that is utilized to
elicit a voluntary muscle
contraction.
SEQUENCING-
• Weight bearing with control precedes
non-weight bearing movement
without control.
• Isometric-eccentric-concentric.
-Progression of activity in skeletal
muscle that moves from easier to
more difficult.

• Proximal to distal key points.
-To withdraw your feedback or control
over the movements in a gradual way

• Small ROM to larger ROM of
movement with control
- Once pt. has control in small
movement – increase ROM

• Slow to fast movement
- Once pt. has control in slow – increase
speed

65

Key Elements to NDT - HANDLING***
Key points

• Specific handling of certain areas
of the body

• Influence and facilitate posture,
alignment, and control.
• Shoulder
• Pelvis
• Hand
• Foot/ankle
• Toes
• Fingers/wrists

66

Key Elements to NDT - Placing
Reflex inhibiting postures (RIPs): what is it?

• Designated static positions that Bobath
found to:
• Inhibit abnormal tonal influences and reflexes.

67

Key Elements to NDT - Placing
Reflex inhibiting postures (RIPs): of UE

shoulder in ER, elbow in extension

68

Key Elements to NDT - Placing
Reflex inhibiting postures (RIPs): of LE

hip in abduction, ER, and extension; knee
in extension, ankle and toes in DF, great toe in
abduction (therapist places finger btwn great toe
and second toe)

69

Key Elements to NDT - Placing
Reflex inhibiting postures (RIPs): of trunk

rotate the shoulder girdle against the
pelvis

70

Key Elements to NDT- Practice

• The act of moving an extremity
into a position that the patient
must hold against gravity
• Patient must be taken care of
24/7 if carryover is expected
• Practice increases retention
• Functional
• Sensory functional
• Sensory-motor experiences

71

Facilitate Trunk Control
Rolling:

use trunk righting
reaction and protect the
affected arm
- Head and trunk stay in midline
- Hold affected arm by the elbow or
the wrist

72

Facilitate Trunk Control
Supine-to-sit

- Maintain trunk elongation
- Weight bear through UE as
tolerated

73

Facilitate Trunk Control
Sitting

Sitting (upright posture
indicates anti-gravity control)
- Upright sitting posture (equal
weight bearing) and elongate
trunk on the affected side
- Sitting balance (use protective
extension of arms)
- Facilitate trunk control laterally,
forward/backward, and
rotationally (use arms)

74

Facilitate Trunk Control
Others

- Consider quadruped, but difficult for an elderly person
- Consider kneeling, half kneeling
- Sit to stand

75

Preambulation Skills

- Ankle, knee, and hip control in
bed
- Bring the leg into flexion and hold
at different angles
- Prevent hip adduction and internal
rotation

- Bridging exercises
- Facilitate control of the affected
hip
- Avoid lifting the trunk too high

- Transfer (Mat to Wheelchair)
from the affected side

- LE control in sitting (both feet on the ground)
- Facilitate active knee and ankle control in sitting
- Flex the affected knee beyond 90 degrees

- Swiss ball exercises (in sitting) to facilitate upright posture

- Standing posture (equal weight bearing)

- Weight shifting in standing with different base of support and feet
positions

76

Ambulation Skills

- Facilitate affected leg to bear weight
- Move the sound leg forward/backward
- Standing will cause weight bearing and compression→ will increase
the extensor tone of the affected leg
- Facilitate pelvic movement (prevent protraction or retraction)

77

Cueing hip extensors during gait

- Cue hip extension during mid to
terminal stance
- Cue may include assist for forward
progression of trunk over stance
limb

78

Cueing hip flexors to initiate swing

- Tap over hip flexor muscle/tendon at
toe off. Timing is important!

79

Cueing the pelvis to rotate

- Walk backward in front of the
patient or behind them
- Therapist’s hand should be on
ASIS
- “Push into my hand” cue given
at initial swing