Physical Therapy for

Hemiplegia Patients

物理治療師陳貞吟

Theories for stroke rehabilitation

• Brunnstrom theory

• PNF theory

• Motor relearning theory

• Bobath theory: – NDT: Neural-Developmental Theory

Brunnstrom Theory

• Aim– To encourage the return of voluntary movemereturn of voluntary moveme

ntnt in hemiplegia patient through the use of refluse of reflex activity and a range of sensory stimulationex activity and a range of sensory stimulation.

– The choice of stimulation varies depending on depending on which stagewhich stage the patient has reached in the recovery process.

Brunnstrom Theory

• Basis of practice– Recovery progresses from subcortical to cortical co

ntrol of muscle function.– The stages of recovery

1. Flaccidity2. Presence of basis synergy on a reflex level3. Voluntary control of the movement synergies4. Ability to mix components of antagonistic synergies but infl

uence of spasticity still observable5. More difficult movement combinations mastered; limbs syn

ergies lose their dominance6. Individual joint movements become possible7. Normal motor function is restored.

Brunnstrom Theory

• Treatment– The choice and use of sensory stimulation depends depends

on the stage of recovery.on the stage of recovery.– The process is employed until the primitive synergiesprimitive synergies

are established, then facilitationthen facilitation is used to develop some voluntary control.

– The preparation for walking should be emphasized early but that extensive walking should be postponed in order to avoid the development of a poor gait pattern

PNF Theory

• Proprioceptive Neuromuscular Facilitation

• Primary for the patient with neuromuscular dysfunction

• Aim– to promote movement and functional synergi

es of movement by maximizing peripheral inpby maximizing peripheral inputut

PNF Theory

• Basis of practice – People who move normally have passed

through a developmental sequencedevelopmental sequence– Diagonal and spiral patternsDiagonal and spiral patterns of active and

passive movements are encouraged

• Treatment– Providing appropriate sensory stimulus– Following activities in a developmental

sequence• Patterns and techniques

Motor relearning Theory

• By Carr and Shepherd

• Aim– To enable the disabled person to learn how to to learn how to

perform or improve performanceperform or improve performance of actions critical to everyday life.

– Utilizing theories of learningtheories of learning, in particular the use of practice and knowledge of results to encourage people to learn and self monitor

– Knowledge of biomechanics for analyzing movements and performance of tasks

Motor relearning Theory

• Basis of practice– The motor control of posture and movement are

interrelated and that appropriate sensory input will help modulate the motor response to a task

– The program is based on• Elimination of unnecessary muscle activity• Feedback• Practice• The link between postural adjustment and movement

• Task analysis and measurement are viewed as essential elements of the framework.

Motor relearning Theory

• Treatment– Movement analysis and training follow the four steps

• Analysis of the task• Practice of the missing components• Practice of the task• Transference of training

– A series of task has been chosen because learning by normal subjects has been shown to be task-specific with minimal carry-over from one activity to another

Bobath theory: NDT

• Aim– To improve the quality of movement on the affected the quality of movement on the affected

sideside– Key point controlKey point control is to allow patients the experience of

normal afferent input• Basis of practice

– The movement will be abnormal if it stems from a background of abnormal toneabnormal tone

– Performing abnormal movements will reinforce more abnormal movements

– Tone could be influenced by altering the position or movement of proximal joints of the body

Bobath Theory: NDT

• Treatment– Treatment centre around the facilitation of

corrected movement by a therapist who handles the body at key points of controlkey points of control

– In recent years treatment has become more active , dynamic and functionally directedactive , dynamic and functionally directed ..

– Movement are not isolated to individual joints but take place in patterns

Bobath theory: NDT

– To help the patient to gain control over the released patterns of spasticity by their own inhibition

• Auto-inhibition

– Give patient normal kinematics sensation input to facilitated normal posture and movement

– Muscle strengthening is notnot viewed as part of treatment

– There are no set “Bobath exercise”

Clinical practice

• Rehabilitation by compensation is to a large extent responsible for an increase in spasticity and for the inactivity of the involved side

• Patient and PT must work together.

• People learn best in different ways

Clinical practice

• Trunk alignment and activity are critical aspects of limb movement

• Appropriate preparatory postural responses• Weight bearing is an effective tool• Safe function Safe balance• No good alignment, no normal movement

– Correct posture alignment

• Give enough sensory input( visual, auditory, tactile, proprioception …) – Facilitation

Clinical practiceNormal lying posture

Clinical practicenormal sitting posture

Clinical practicenormal pattern from lying to sit