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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
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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.
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職能治療技術學 劉倩秀老師 03/04/2009
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.
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職能治療技術學 劉倩秀老師 03/04/2009
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
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職能治療技術學 劉倩秀老師 03/04/2009
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.
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職能治療技術學 劉倩秀老師 03/04/2009
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.
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職能治療技術學 劉倩秀老師 03/04/2009
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.
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職能治療技術學 劉倩秀老師 03/04/2009
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.
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職能治療技術學 劉倩秀老師 03/04/2009
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.
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職能治療技術學 劉倩秀老師 03/04/2009
Cont.
6 Even when only partial movement is possible, stress reversal of movement from flexion to extension in each treatment session.
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職能治療技術學 劉倩秀老師 03/04/2009
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.
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職能治療技術學 劉倩秀老師 03/04/2009
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.
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職能治療技術學 劉倩秀老師 03/04/2009
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.
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職能治療技術學 劉倩秀老師 03/04/2009
Evaluation
SensationTonic reflexesAssociated reactionsLevel of recovery of voluntary movement
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職能治療技術學 劉倩秀老師 03/04/2009
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)
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職能治療技術學 劉倩秀老師 03/04/2009
Cont.
Tonic reflexesTonic reflexes are assessed to determine whether they can be used in early treatment to initiate movement when none exists.
ATNRSTNRTLRTonic lumbar
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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
職能治療技術學 劉倩秀老師 03/04/2009
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TLR- prone position TLR – supine position
職能治療技術學 劉倩秀老師 03/04/2009
http://www.prekop-institut.com/publikationen.html
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STNR – in extension STNR – in flexion
職能治療技術學 劉倩秀老師 03/04/2009
www.sarahmarshall.co.uk/images/prim2_6.jpg
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職能治療技術學 劉倩秀老師 03/04/2009
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
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職能治療技術學 劉倩秀老師 03/04/2009
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
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職能治療技術學 劉倩秀老師 03/04/2009
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”
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職能治療技術學 劉倩秀老師 03/04/2009
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職能治療技術學 劉倩秀老師 03/04/2009
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”
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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
職能治療技術學 劉倩秀老師 03/04/2009
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職能治療技術學 劉倩秀老師 03/04/2009
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
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職能治療技術學 劉倩秀老師 03/04/2009
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.
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職能治療技術學 劉倩秀老師 03/04/2009
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
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職能治療技術學 劉倩秀老師 03/04/2009
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)
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職能治療技術學 劉倩秀老師 03/04/2009
Level of recovery of voluntary movement
The Brunnstrom stagesThe Fugl-Meyer Assessment of Motor Function
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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
職能治療技術學 劉倩秀老師 03/04/2009
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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
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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
職能治療技術學 劉倩秀老師 03/04/2009
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職能治療技術學 劉倩秀老師 03/04/2009
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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
職能治療技術學 劉倩秀老師 03/04/2009
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職能治療技術學 劉倩秀老師 03/04/2009
Treatment
1. Rehabilitation trunk control2. Retraining proximal upper extremity
control
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職能治療技術學 劉倩秀老師 03/04/2009
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
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職能治療技術學 劉倩秀老師 03/04/2009
Trunk forward flexion
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職能治療技術學 劉倩秀老師 03/04/2009
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
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職能治療技術學 劉倩秀老師 03/04/2009
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職能治療技術學 劉倩秀老師 03/04/2009
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
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職能治療技術學 劉倩秀老師 03/04/2009
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
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職能治療技術學 劉倩秀老師 03/04/2009
Develop elbow extension - rowing
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職能治療技術學 劉倩秀老師 03/04/2009
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職能治療技術學 劉倩秀老師 03/04/2009
Develop elbow extension - weight bearing
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職能治療技術學 劉倩秀老師 03/04/2009
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職能治療技術學 劉倩秀老師 03/04/2009
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
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職能治療技術學 劉倩秀老師 03/04/2009
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職能治療技術學 劉倩秀老師 03/04/2009
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
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職能治療技術學 劉倩秀老師 03/04/2009
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
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職能治療技術學 劉倩秀老師 03/04/2009
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
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職能治療技術學 劉倩秀老師 03/04/2009
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職能治療技術學 劉倩秀老師 03/04/2009
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
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職能治療技術學 劉倩秀老師 03/04/2009
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職能治療技術學 劉倩秀老師 03/04/2009
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..)
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The first motion of stages VCombine
Shoulder side horizontal / abductionElbow extension
table tennis, driving golf ball, hitting a baseball, washing dishes (F25-13)…
職能治療技術學 劉倩秀老師 03/04/2009
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職能治療技術學 劉倩秀老師 03/04/2009
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
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職能治療技術學 劉倩秀老師 03/04/2009
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
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職能治療技術學 劉倩秀老師 03/04/2009
http://ligwww.epfl.ch/~maurel/Pictures/CHARM/WP3/serratus_anterior.gif
http://depts.washington.edu/msatlas/shserant.html
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職能治療技術學 劉倩秀老師 03/04/2009
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