ch25 optimizing motor behavior using the brunnstrom...

CH25 Optimizing motor behavior using the

Brunnstrom Movement Therapy Approach

p.667-689

職能治療技術學劉倩秀老師

職能治療技術學劉倩秀老師 03/04/2009

Assumptions of the Brunnstrom Movement Therapy Approach

In normal motor development, spinal cord and brainstem reflexes become modified and their components become rearranged into purposeful movement through the influence of higher centers.


Cont.

Because reflexes and whole-limb movement pattern are normal stages of development and because stroke appears to result in “development in reverse,”

reflexes and primitive movement patterns should be used to facilitate the recovery of voluntary movement post stroke.

Proprioceptive and exteroceptive stimuli can be used to evoke desired motion or tonal changes.


Cont.

Recovery of voluntary movement post stroke proceeds in sequence from mass stereotyped flexor or extensor movement patterns to movements that combine features of the two patterns and, finally, to discrete movements of each joint at will.

Newly produced correct motions must be practiced.

Practice within the context of daily activities enhances the learning process


Principles of the Brunnstrom Movement Therapy Approach

1 Treatment progresses developmentally from evocation of reflex response to willed control of voluntary movement to automatic functional motor behavior.


Cont.

2 When no motion exists, facilitate it using reflexes, associated reactions, proprioceptive facilitation, and/or exteroceptive facilitation to develop muscle tension in preparation for voluntary movement.


Cont.

3 Elicit reflex responses and associated reactions in combination with the patient’s voluntary effort to move, which produces semi-voluntary movement; this allows the patient to feel the sensory feedback associated with movement and the satisfaction of having moved to some degree voluntarily.


Cont.

4. Proprioceptive and exteroceptive stimuli also assist in eliciting movement.

Resistance, a proprioceptive stimulus, promotes a spread of impulses to other muscles to produce a patterned response (associated reaction),

whereas tactile stimulation (exteroceptive) and muscle or tendon tapping (proprioceptive) facilitate only the muscle related to the stimulated area.


Cont.

5 When voluntary effort produces a response, ask the patient to hold (isometric) the contraction.

If successful, ask for an eccentric (controlled lengthening) contraction and finally a concentric (shorting) contraction.


Cont.

6 Even when only partial movement is possible, stress reversal of movement from flexion to extension in each treatment session.


Cont.

7 Reduce facilitation as quickly as the patient shows evidence of volitional control.

Drop out facilitation procedures in order of their stimulus-response binding.

Reflexes are the most primitive and are dropped out of treatment first.

Responses to exteroceptive stimulation are least stereotyped, and therefore, tactile stimulation is eliminated last.

No primitive reflexes, including associated reaction, are used beyond stage III.


Cont.

1. Place emphasis on willed movement to overcome the linkages between parts of the synergies.

Patient may be more successful if you ask them to do familiar movements involving a goal object.


Cont.

9 Have the patient repeat correct movement, once elicited, to learn it.

Practice should involve functional activities to increase the willed aspect and to relate the sensations to goal-directed movement.


Evaluation

SensationTonic reflexesAssociated reactionsLevel of recovery of voluntary movement


Cont.

SensationThe sensory evaluation precedes the motor evaluation.

The results of sensory evaluation guide the therapist’s choice of facilitation modalities to improve movement….

CH7 , p.223Touch awarenessPinprick or pain awarenessTemperature awarenessProprioceptionKinethesia (運動覺)


Cont.

Tonic reflexesTonic reflexes are assessed to determine whether they can be used in early treatment to initiate movement when none exists.

ATNRSTNRTLRTonic lumbar

ATNR Tonic lumbar reflex

Sti: rotate upper trunk in relation to the pelvis

Response: Increased flexor tone in U/E, extensor tone in L/E on the side toward which the trunk is turned


TLR- prone position TLR – supine position


http://www.prekop-institut.com/publikationen.html

STNR – in extension STNR – in flexion


www.sarahmarshall.co.uk/images/prim2_6.jpg


Cont.

Associated reactions(協同反應;聯合反應)Associated reaction are involuntary movements, reflexive increases of tone in muscles that would be expected to contract to cause the movement.Be triggered by effortful voluntary movement


Cont.

Basic limb synergies (協同動作)Limb synergies are instances of associated reactions.

When the patient initiates a movement of one joint, all muscles that are linked in synergy with that movement automatically contact, causing a stereotyped movement pattern (固著化的動作型態).

Flexor synergyU/E; L/E

Extensor synergyU/E; L/E


Cont.flexor synergy of upper extremity

Scapular retraction / elevationShoulder abduction and external rotationElbow flexion (strongest component)Forearm supinationWrist and finger is variable

Instruction:“Touch your ear”


Cont.Extensor synergy of upper extremity

Scapular protractionShoulder horizontal adduction and internal rotation (strongest component)Elbow extensionForearm pronationWrist and finger is variable

Instruction:“Reach out to touch your opposite knee”

Cont.

Upper extremity flexor synergy usually develops before extensor synergy.

When both synergies are developing and spasticity is marked, the strongest components of the flexion and extension synergies sometimes combine to produce the typical upper extremity posture in hemiplegia:

Add and internal rotatedElbow flexedForearm pronatedWrist and fingers flexed



Cont.

Flexor synergy of lower synergyHip flexion (strongest component), abduction, and external rotationKnee flexionDorsiflexion and inversion of the ankleToes dorsiflexion

Extensor synergy of lower synergyHip extension, adduction, and internal rotation;Knee extensionAnkle plantar flexion and inversion (strongest component)Toes plantarflexion


Cont.

Other associated reactions identified by Brunnstrom

1. Resistance to flexion of the uninvolved leg causes extension of the involved extremity, and resistance to extension of the uninvolvd leg cause flexion of the involved extremity.


2. Resisted grasp by the uninvolved hand causes a grasp reaction in the involved hand. (mirror synkinesis)鏡像協同動作

3. Attempt to flex the involved leg or resistance to leg flexion causes a flexor response in the involved arm. (homolateral synkinesis)同側協同動作


4. Actively or passively raising the affected arm above the horizontal causes the fingers to extend and abduct. (Souque’s phenomenon)

raising the involved upper extremity above 100 degrees with elbow extension will produce extension and abduction of the fingers

5. Resistance to abduction or adduction of the unaffected lower limb results in a similar response in the opposite affected leg. (Raimiste’s phenomenon)


Level of recovery of voluntary movement

The Brunnstrom stagesThe Fugl-Meyer Assessment of Motor Function

Brunnstrom stages

Arm I. flaccidity: no voluntary movement or stretch reflexesII. Synergies can be elicited reflexively; flexion develops before extension; spasticity developingIII. Beginning voluntary movement, but only in synergy; increased spasticity, which may become marked


IV: some movements deviating from synergies1. Hand behind back2. Arm forward horizontal position3. Pronation and supination with the elbow flexed to 90°;

spasticity decreasingV: independence from basic synergies1. Arm to side horizontal position2. Arm forward and overhead3. Pronation and supination with elbow fully extended;

spasticity waningVI: isolated joint movements freely performed with near normal coordination; spasticity minimal職能治療技術學劉倩秀老師 03/04/2009

Hand 1. Flaccidity2. Little or no active finger flexion3. Mass grasp or hook grasp; no voluntary finger extension

or release4. Semi-voluntary finger extension in a small range of

motion; lateral prehension with release by thumb movement

5. Palmar prehension1. Cylindrical and spherical grasp (awkward)2. Voluntary mass finger extension (variable range of motion)

6. All types of prehension (improved skill)1. Voluntary finger extension (full range of motion)2. Individual finger movements


Evaluation to determine (Practice 25-2)

1. Propriceptive and exteroceptive sensory status

2. Effect of tonic reflexes on the patient’s movement

3. Effect of associated reactions on the patient’s movement

4. Level of recovery of voluntary motor control



Treatment

1. Rehabilitation trunk control2. Retraining proximal upper extremity

control


Rehabilitating trunk control

Hemiplegia: poor trunk controlPromote contraction of trunk muscles on uninvolved side first by pushing off balance toward the involved side

Trunk extension / flexion


Trunk forward flexion


Retraining proximal upper extremity control

General format for treatment practice 25-4

Because recovery proceeds sequentially, once the stage of recovery is identified, the short-tern goal is the next step in the sequence

Stages I to IIIStages IV to VI


Stages I-III

Treatment goal:To promote voluntary control of the synergies To encourage their use in functional activities

Stages I to IIFrom flaccidity to beginning synergy

Using reflexes, associated reactions, facilitation procedures


1. Initiate scapular elevationPosition: patient’s arm supported on a table in shoulder abduction with elbow flexionPatient is asked to lateral flexion of neck toward the involved sideTherapist gives resistance to the head and shoulder

2. Active contraction by associated reactionPatient is asked to bilateral scapular elevation,

Therapist give resistance to the uninvolved scapular

As patient elevate scapular with associated reaction

Therapist give resistance to the involved scapularPatient is asked to hold it


Develop elbow extension - rowing


Develop elbow extension - weight bearing


Practice extensor synergy functionally

Put the arm into the sleeve of a garmentTo smooth out a sheet on the bedTo sponge off the kitchen counter


Practice flexor synergy functionally

Carrying coat or handbag Feeding oneselfPutting on glassesCombing the hair

Practice both synergies functionally

Sanding, weaving, ironing, polishingAlternating and repeating movement


Stages IV to VI

Treatment goal:To promote movement deviating from synergy“condition the synergies”, To promote voluntary movement combining components of the two synergies into increasingly varied combinations of movements that deviate from synergy

TechniqueProprioceptive and exteroceptive stimuli are still usedAssociated reaction is no longer used


The first out-of-synergy motion of stages IVCombine

Shoulder abduction (flexor synergy)Elbow extension, forearm pronation, internal rotation (extensor synergy)

A swinging motion of the arm combined with trunk rotation helps to get the hand behind the body.

Sitting or standing The patient strokes the dorsum of the hand against the body (give the direction to the attempted voluntary movement)Functional tasks

Putting a belt on when the patient is standingTucking a shirt into trousers


The second out-of-synergy motion of stages IVCombine

Shoulder flexion with foreword horizontal Elbow extension

If the patient cannot flex the shoulder forward actively…..The arm is brought passively into position

Manual guidanceAsk patient to hold the position

Facilitating technique – tapping over the anterior and middle deltoids muscles

If the patient can hold the after positioningPatient is asked to lower of the arm followed by active shoulder flexion

Stroking of triceps are used to help the patient keep the elbow straight as the arm is raised

Repetitive non-resistive activities Raising the arm to forward horizontal is involved in any vertically mounted games (tick-tac-toe, checkers (Velcro tabs) )Reaching for objects in a cupboard


The third out-of-synergy motion of stages IVcombine

forearm pronation elbow flexion

Functional activities forearm pronate while elbow extensionelbow can be brought into flexion gradually

Activities require turning objects (knob, screwdriver..)

The first motion of stages VCombine

Shoulder side horizontal / abductionElbow extension

table tennis, driving golf ball, hitting a baseball, washing dishes (F25-13)…



The second motion of stages VSerratus anterior must be specifically retrained.Passive mobilization of the scapula

Grasping the vertical border and repeatedly and slowly rotating it as the arm is passively moved into and overhead position

Placing the arm in forward horizontal position and asking and assisting the patient to reach forward

Therapist moving the arm incrementally overheadPractice with functional activities

Bilateral sanding boxPutting on overhead garments every dayWashing a wall or painting it with roller


What drives upward rotation of the scapula?

During the early phase of upward rotation, the scapula and the clavicle move together around an axis through the sternoclavicular (SC) joint, the only joint where the scapula and shoulder girdle attach to the axial skeleton. The SC joint's antero-posterior (AP) axis is somewhat oblique and passes near the base of the scapular spine. Around this axis, serratus anterior (SA) and upper trapezius (UT) produce upward rotation moments.

Once tension in the costoclavicular ligament prevents further elevation of the clavicle at the sternoclavicular joint, the axis for scapular rotation moves to the acromioclavicular (AC) joint. The "X" illustrates the AC joint's antero-posterior axis. Around this axis, the serratus anterior (SA) and the lower trapezius (LT) produce upward rotation moments.

http://moon.ouhsc.edu/dthompso/namics/uprot.htm


http://ligwww.epfl.ch/~maurel/Pictures/CHARM/WP3/serratus_anterior.gif

http://depts.washington.edu/msatlas/shserant.html


The third motion of stages VCombine

Forearm supinationElbow extension

To improve supination, the elbow is at first kept close to the trunk and gradually extended.Patients use both hands in activities of interest that entail supination and pronation in various arm positions

Grasping beach ball with the arms outstretched and rotating it

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