BRUNNSTROM MOVEMENT THERAPY

Evaluation

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Tonic reflexes

(STNR, ATNR, tonic labyrinthine "supine & prone", tonic lumbar reflex, tonic thumb reflex, +ve supporting reaction, -ve local static reaction, tonic thumb reflex and flexor withdrawal reflex).

Influence of reflexes:

Varying degrees of influence of the postural reflexes may be noted, and are often associated with spasticity and synergy involvement.

Symmetric Tonic Neck Reflex (STNR):

Flexion of the neck results in flexion of the arms and extension of the legs; extension of the neck results in extension of the arms and flexion of the legs.

Asymmetric Tonic Neck Reflex (ATNR):

Head rotation to the left causes extension of left arm and leg and flexion of right arm and leg; head rotation to the right causes extension of right arm and leg and flexion of left arm and leg.

Tonic Labyrinthine Reflex (TLR):

Prone lying position facilitates flexion; the supine position facilitates extension. The reflex can also be thought of as inhibition of extensor tone in the prone position.

Tonic Lumbar Reflex:

This is initiated by a change in the position of the upper trunk with respect to the pelvis. Rotation of the trunk to the right results in flexion of the right upper extremity and extension of the right lower extremity; rotation of the trunk to the left results in extension of the right upper extremity and flexion of the right lower extremity.

Tonic thumb reflex:

When the affected upper extremity is elevated above the horizontal with forearm supination, thumb extension is facilitated (pronation is facilitatory to finger extension).

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Associated reactions:

Associated reactions are automatic responses of the involved limb resulting from action occurring in some other part of the body, either by voluntary or reflex stimulation (e.g., resistance or ATNR). They are commonly elicited when some degree of spasticity is present and are infrequently seen in a limb exhibiting minimal muscle tone. Generally speaking, although not true in every case, associated reactions elicit the same direction of movement (i.e., flexion evokes flexion) and the opposite direction (i.e., flexion evokes extension) in the lower extremity.

 

Souques’ Phenomenon:

Elevation of the affected arm above the horizontal evokes an extension and      abduction response of the fingers.

Raimiste’s Phenomenon:

Resistance applied to abduction or adduction of the nonaffected lower extremity evokes a similar reaction in the affected limb.

Homolateral Limb Synkineses:

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

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Sensory evaluation:

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

• Touch sensation: The palmer aspect of the finger tips are touched with a rubber end of a pencil and the patient is asked to determine without looking which fingertip is touched.

• Sole sensation: the patient, without looking, is asked to determine if an object is touching and pressing against his sole of the foot or not and where.

 

Voluntary control of movement: recovery occurs in stereotyped sequence of events

 

Stages of recovery of extremities are as follows:

1. Period of flaccidity immediately following acute episode no movement of limbs can be elicited.

2. Basic limb synergies begin to develop or some of their components may appear as associated reactions or minimal voluntary movement. flexor synergy appears before extensor synergy. At this time spasticity begins to develop.

3. Patients gain voluntary control of movement synergies, although full range of all synergy components does not necessarily develop. Spasticity increases and becomes severe.  

4. Some movement combinations that do not follow either synergies i.e.arm behind the back, arm to forward horizontal position, pronation and supination with elbows flexed to 90* are mastered first with difficulty then with ease. Spasticity begins to decline.

5. More difficult movement combinations i.e. Shoulder abduction, overhead flexion, pronation and supination with elbow fully extended are learned as basic synergies lose their dominance over motor acts.

6. Individual joint movements become possible and coordination approaches. Normal motor function is restored. Disappearance of spasticity.

 

Stages of recovery of hand:

1. Flaccidity

2. Little or no active finger flexion

3. Mass grasp or hook grasp, no voluntary finger extension or release

4. Semi-voluntary finger extension in small ROM, lateral prehension by release of thumb movement

5. Palmar prehension

   1. Cylindrical and spherical grasp

   2. Voluntary mass finger extension (variable ROM)

6. All types of prehension

   1. Voluntary finger extension(full ROM)

   2. Individual finger movements

 

 

Lower limb motor control:

1. Flaccidity

2. Minimal voluntary movement of lower limb

3. Hip knee ankle flexion in lying and standing 

4. ​

   1. Sitting knee flexion beyond 90* with food sliding backward on floor 

   2. Voluntary dorsiflexion of ankle without lifting foot off the floor

5. ​

   1. Standing isolated non weight bearing knee flexion with hip in extension or nearly extended

   2. Standing isolated dorsiflexion of ankle with knee in extension

6. ​

   1. Standing hip abduction beyond range obtained by elevation of pelvis 

   2. Sitting reciprocal action of inner and outer hamstring muscle, combined with eversion and inversion of foot

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Assessment of basic limb synergies:

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Synergy means: stereotype whole limb movement.

There are two synergies for U.L. and two synergies for L.L.: flexor & extensor.

 

Flexor synergy of U.L:

It consists of

Scapula: retraction & depression

Shoulder: flexion, abduction, external, and rotation,

Elbow: flexion to acute angle,

Forearm: supination,

Wrist & fingers: variable. Most commonly flexed

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The strongest component: elbow flexion

The weakest component: shoulder abduction & external rotation.

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Extensor synergy of U.L:

It consists of

Scapula: protraction,

Shoulder: extension, adduction, and internal rotation,

Elbow: extension,

Forearm: pronation and

Wrist & fingers: variable. Most commonly flexed

 

The strongest components: adduction (pectoralis major) and pronation.

The weakest component: elbow extension.

 

Flexor Synergy of L.L:

It consists of

Hip: flexion, abduction, external rotation,

Knee: flexion to about 90°,

Ankle: dorsiflexion and inversion,

Toes: dorsiflexion.

 

Strongest component: hip flexion.

Weakest component: hip abduction, external, rotation.

 

Extensor synergy of L.L:

It consists of

Hip: extension, adduction, internal rotation,

Knee: extension,

Ankle: planter flexion, inversion,

Toes: plantarflexion.

 

Strongest components: Hip adduction and Knee: extension.

Weakest component: hip internal rotation.

 

 

Speed test

It can be used to assess spasticity during anyone of the recovery stages, provided that the patient has sufficient active ROM. The patient is seated on a chair without armrest leaning against chair back and keeping the head erect. The two movements studied are:

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

2. The hand is moved from lap to opposite knee, requiring full range of elbow extension.

A stopwatch is used and the number of full strokes completed in 5 seconds is recorded, first on the unaffected then on the affected side.

 

7- Fugl-Meyer Assessment of Motor Recovery after Stroke

The Fugl-Meyer Assessment (FMA) is a stroke-specific, performance-based impairment index. It is designed to assess motor functioning, balance, sensation and joint functioning in patients with post-stroke hemiplegia

The scale is comprised of five domains and there are 155 items in total:

·         Motor functioning (in the upper and lower extremities)

·         Sensory functioning (evaluates light touch on two surfaces of the arm and leg, and position sense for 8 joints)

·         Balance (contains 7 tests, 3 seated and 4 standing)

·         Joint range of motion (8 joints)

·         Joint pain

Scoring:

Scoring is based on direct observation of performance. Scale items are scored on the basis of ability to complete the item using a 3-point ordinal scale where 0=cannot perform, 1=performs partially and 2=performs fully. The total possible scale score is 226.

Points are divided among the domains as follows:

·         Motor score: ranges from 0 (hemiplegia) to 100 points (normal motor performance). Divided into 66 points for upper extremity and 34 points for the lower extremity.

·         Sensation: ranges from 0 to 24 points.  Divided into 8 points for light touch and 16 points for position sense.

·         Balance: ranges from 0 to 14 points.  Divided into 6 points for sitting and 8 points for standing.

·         Joint range of motion: ranges from 0 to 44 points.

·         Joint pain: ranges from 0 to 44 points.

Classifications for impairment severity have been proposed based on FMA Total motor scores (out of 100 points):

< 50 = Severe

50-84 = Marked

85-94 = Moderate

95-99 = Slight