BRUNNSTROM MOVEMENT THERAPY

Treatment Procedure

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• Bed posture and treatment during stage of flaccidity

• Rehabilitation in trunk control

• Proximal upper extremity control

• Improving hand and wrist function

• Rehabilitation in lower limb motor control

• Gait training

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Bed Posture and Treatment during Stage of Flaccidity

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• When flaccid condition prevails, the positioning of limbs in the bed should be without interference of spastic muscles

• In supine- slight hip and knee flexion maintained with pillows and provide lateral support to knee to prevent hip abduction and external rotation

• No clothing should come in contact with foot

• The affected upper limb is supported on pillow in a position that is comfortable for patient

• Avoid traction to prevent shoulder subluxation

• While the flaccidity predominates, passive motions of the limb are first carried out and then developed into active assisted movements.

• Include head, neck and trunk movements, teach bed mobility- rolling bridging, sitting.

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Rehabilitation in Trunk Control

 

Rehabilitation of trunk control precedes treatment of the limbs

1. Brunnstrom emphasized promoting contraction of uninvolved trunk muscles-

   • Give perturbation by pushing the patient off balance towards the involved side, while guarding in case of poor response

   • Give reach out to the uninvolved side –across the midline

2. Recovery from a push toward or reach toward the uninvolved side is sought-

   • This requires contraction of the trunk muscles on the involved side.

   • The patient is pushed or asked to reach only to the point at which he can maintain balance.

   • hold the position and regain upright posture.(return to starting position)

3. Training then progresses to promote trunk flexion, extension, and rotation

4. Forward flexion of trunk-

   • The patient crosses the arms with the uninvolved hand under involved elbow and uninvolved forearm supporting the involved forearm. The therapist sits facing the patient, supporting him under elbow and assist in trunk forward flexion.

   • Return from trunk flexion is performed actively by patient.

5. Facilitate active trunk extension- sitting without back support perturbations are given with active trunk extension.

6. Forward flexion in oblique direction- promotes regaining balance also incorporates scapular motion with shoulder flexion already achieved.

7. Trunk rotation- combined with the head rotations in opposite direction so that TNR and TLR can be used elicit the shoulder components of upper extremity synergies

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Proximal Upper Extremity Control

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I to III   promote voluntary control of synergies to encourage their use in functional activities

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I Basic limb synergies are elicited at a reflex level using reflex response and associated reactions and facilitation procedures

1. Elbow flexion – the strongest component of that synergy is the first motion to be elicited

2. Scapular elevation-

   • Lateral flexion of neck towards the uninvolved side: can be used to initiate scapular elevation. Patients arm supported on table in shoulder abduction with elbow flexion, and the movement is resisted by therapist. Command-“take your ear towards your shoulder and lift shoulder upwards and don’t let me move it away”

   • Bilateral scapular elevation: associated reactions are used by resisting the uninvolved side and asking for bilateral contraction with hold

   • Unilateral scapular elevation: the therapist supports patients arm and assists the patient to elevate scapula along with exteroceptive stimuli follow as isometric, eccentric, concentric contractions of trapezius. Gently abduct the shoulder in increasing increments.

3. External rotation and forearm supination: active abduction at shoulder along with external rotation and forearm supination are included with shoulder elevation.

Reversal to opposite direction is done and this begins to develop some components of extensor synergy.

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II Contraction of pectoralis major:

Associated reaction-therapist supports patients arm in a position between horizontal abduction and adduction and instructs to bring his arms together and resists uninvolved arm proximal to elbow. Instructions-“don’t let me pull your arms apart.”

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III Facilitate elbow extension:

1. Use tonic labyrinthine reflex and ATNR in supine position with forearm pronated and rotating trunk to uninvolved side to facilitate via tonic lumbar reflex.

2. Rowing:

   • Sit facing patient

   • Cross your arms so that your right hand grasps patient’s left hand and the left hand grasps the right one.

   • Resist as the pronated, uninvolved arm moves towards involved knee- this evokes associated reaction to opposite elbow extensors also assist involved arm into extension towards opposite knee.

   • Combine extension with pronation and flexion with supination.

   • Once active contraction is achieved resist bilateral movement.

   • Apply quick stretches to triceps.

3. Weight bearing: use exteroceptive stimuli over triceps

   • Ask patient to lean on extended arms supported by low stool

   • Have the patient shift weight so that involved extremity bears more  weight of upper trunk

   • Unilateral weight bearing position-hold down objects with affected arm e.g. holding package steady while opening it, supporting body weight while polishing or washing large surfaces.

4. Functional activities: push arm into sleeves of garment, smooth out sheet on bed, wipe a surface, carry items in hand, sanding, weaving, ironing, polishing.

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IV to VI Promote dissociation of synergies along with willed movement and isolated control, extensor synergy tends to follow flexor synergy.

 

IV Some movements deviating from synergy: Movements that combine components of synergy:

1. Shoulder abduction in conjunction with elbow extension: breaks synergistic relation between synergy. Patient begins to extend in response to unilateral manual resistance and guides the movement towards greater shoulder abduction with elbow extended.

2. Hand behind the body: strongest component of each synergy is subdued. Swinging motion of arm combined with trunk rotation helps to get hand behind body. As the hand reaches the back, the patient strokes it against body to complete sensory awareness of movement. If patient is unable to do so, the therapist assists him. Practice with functional task such as putting a belt, tucking a shirt into trousers.

3. Shoulder flexion to forward horizontal position with elbow extended: if this movement is not actively done, the therapist assists or passively gets the arm into position with exteroceptive stimulus over anterior deltoid. Once active contraction achieved ask to hold the position then reverse.

4. Pronation and supination with elbow flexed to 90*: initially, pronation can be resisted with elbow extended, and gradually, the elbow can be brought into flexion. Practice should include activities such as block printing turning objects such as knob, a screwdriver, or a dial, to rein force it. some games, such as skittles, are knob operated and require rotary motions, as do card games that require turning the cards over and the adapted dice game are suggested

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V Active attempts by patients to move in patterns increasingly away from synergy:

Training and tails active attempts by patient to move in patterns increasingly away from synergy. Excess of effort is avoided so that the limbs may not revert back to stereotyped movements. Each new motion is incorporated into functional activities.

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1. Shoulder abduction with elbow extension: the activity combines shoulder abduction with elbow extension. When active movement is not possible passive movement with guidance to active assisted movement is performed. Facilitation on anterior, middle deltoid is given. Reversals and repetition are encouraged.   

2. Arm overhead: The scapula must upwardly rotate. The serratus anterior retain to do this if the retractors are spastic passive mobilization of scapula is necessary by grasping the vertebral border by slowly rotating it as the arm is passively moved into an overhead position. Activate serratus anterior by applying quick stretches by pushing backward into retraction then seek isometric hold followed by reversal. Use in functional activities.  

3. Supination and pronation with elbow extended: the elbow is first kept close to trunk then gradually extended. Activities such as – grasp a beach ball with arms outstretched and rotating it so that the affected arm is on top (pronated) and the unaffected arm is on bottom (supinated) and vice versa

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VI Individual joint movements:

Practice with functional tasks and active movement of individual joints.

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Improving Hand and Wrist Function

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Training techniques for return of function in hand are presented separately from the rest of upper extremity because the hand may be at different stage of recovery from that of the arm 

      

I If active finger flexion cannot be elicited, facilitate it using:

• Associated reaction by resisted grasp 

• Traction stretch to scapular adductors which produces reflex finger flexion used in combination with voluntary effort.

• Start voluntary grasp along with wrist flexion with elbow extended and gradually progress to extension.(ask to squeeze)

• Ask for hold. Start with isometric followed by eccentric than concentric contraction.

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II Stability of wrist extensors:

• Wrist extension is facilitated by flexing fingers and extending elbow   and facilitate for forceful grasp

• Follow techniques with elbow flexed in various degrees 

• Finger release by tapping on dorsum and active effort in wrist extension.

• Practice with wrist flexion extension and circumduction. 

• Ask for hold. Start with isometric followed by eccentric than concentric contraction

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III Finger extension:

• Release grasp by passive extension and abduction of thumb along with supination and pronation of forearm

• Apply cutaneous stimulation over dorsum of hand in supination

• Apply rapid stretch to extensors of fingers   in supination by rolling towards palm 

• Slowly pronate the forearm and elevate arm above horizontal to evoke finger extensor response(souques phenomenon), lower the arm gradually 

• Active finger extension with exteroceptive stimuli give active efforts as grasp and drop large and light objects

• Give functional activities for finger extension by elastic band, smoothening of surface, wiping and sponging.

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IV Lateral prehension with release by thumb

• Release the thumb from lateral prehension  use exteroceptive stimuli- stroke or percuss on extensor pollicis longus and abductor pollicis longus tendons to facilitate this movement 

• Active exercise such as- paper held firmly against tug , holding cards , key, holding heavy book

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V Advance prehensile patterns 

• Reinforce particular prehension at more precise level

• Encourage through activities - holding pencil, glass, ball, fruits etc

• Cylindrical grasp- hold handles of tool

• Spherical grasp- hold round objects 

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VI Individual finger movements 

• Train coordination- improve speed and accuracy 

• Home program - intensive repetitive movements such as pin holding, ball grasping, and holding steady spoon filled with fluid.

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Lower Limb Motor Control

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I Dorsiflexion:

• Elicit reflex response - resist hip flexion, strongest component of flexor synergy.

• Passive plantar flexion of toes elicits mass extensor response (bechterev's reflex).

• Introduce voluntary effort along with facilitation

• Resist both sides with hold in end position, promote isometric followed by eccentric then concentric contraction(give resistance at hip but do not promote hip flexion movement)

• Dorsiflexion in standing- lean on table with buttocks active dorsiflexion with stimulation

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II Minimal voluntary movement of lower limb: Activation of abductor muscles of hip

• Use associated reactions 

• Successive induction: alternate abduction and adduction- resistance on affected side with proper timing 

• Unilateral abduction in side lying practice Isometric, eccentric and concentric contraction.

• Bilateral action of hip abductors- standing swinging leg laterally

• Strengthening and functional use 

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III Hip knee ankle flexion in lying and standing:

• Knee flexors: Evoke reflex response 

• Supine - local stimulation on hamstrings 

• Patient attempts heel slides taking hip closer to body (slides for feedback and proprioception) repeat.

• Sitting - chair sitting knee flexion and heel slides, therapist holds over knee to prevent friction with floor. 

 

IV Sitting knee flexion beyond 90° with food sliding backward on floor:

• Proceed with forward flexion at trunk and increased range of knee flexion 

• Voluntary dorsiflexion of ankle without lifting foot off the floor: 

  • Standing with wall support heel touching wall, give forward reach outs or ask patient to lean forward promoting dorsiflexion 

 

V Standing isolated non weight bearing knee flexion with hip in extension or nearly extended:

• Half prone position - promote knee flexion Along with hip extension 

• Stimulate over hamstring muscles

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VI Standing hip abduction beyond range obtained by elevation of pelvis:

• Unilateral stance with hip hike on unaffected side then practice on affected side. Walking sideways

• Sitting reciprocal action of inner and outer hamstring muscle, combined with eversion and inversion:

  • Dorsiflexion of ankle in sitting assist in eversion and eversion. Proceed to resistance provided medially or laterally to foot.

  • Provide stretch reflex with sudden inversion

  • Isometric, eccentric and concentric contraction.

  • Promote weight bearing with pressure on lateral border of foot 

  • Promote lateral rotation of hip - alternating internal and external rotations at hip joint combine with inversion and eversion.

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Gait Training

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• Restoration of safe standing and safe walking in near normal pattern forms the key components of training procedures.

• Challenging job for the therapist to find ways and means of modifying the gross movement synergies to bring about functional muscle combinations resembling normal locomotion.

• Preparation for gait should commence from the early period- weight bearing exercises and trunk balance in sitting and standing

• Components necessary for normal gait:

  • Modification of motor response to obtain muscle associations resembling those required for normal gait.

  • Reversal of movement direction.

  • Strengthening the weak muscles.

• Treatment should follow a stepwise series of activities with increasing complexity, progressing from least demanding position to most demanding position.

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References

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