Brunnstrom approach

Hierachical theory- says that higher centers control on lower center; but when higher center damage then this inhibitory control from the higher center is loss which leads to exageration of the movt.
In normal individual, these occur a smooth, rhythmic movt. Because there is a presence of control from higher center on lower center.

1. Dr. Maheshwari Harishchandre M.P.Th (Neurosciences) Asst . Professor DVVPF College of Physiotherapy, Ahmednagar Brunnstrom Approach

2. Contents History Aim Basic Limb synergies Attitudinal & postural Reflex Associated reactions Recovery stages Principles of treatment Treatment 4/10/18 2 Brunnstrom approach

3. Objectives Able to describe the stages of Brunnstrom . Able to describe the synergy pattern. 4/10/18 3 Brunnstrom approach

4. History … Developed by Signe Brunnstrom , a physical therapist from Sweden Theoretical foundations: Sherrington Magnus Jackson Twitchell 4/10/18 4 Brunnstrom approach

5. Hierachical theory- says that higher centers control on lower center; but when higher center damage then this inhibitory control from the higher center is loss which leads to exageration of the movt . In normal individual, these occur a smooth, rhythmic movt . Because there is a presence of control from higher center on lower center. 4/10/18 Brunnstrom approach 5

6. Brunnstrom Approach Emphasize on the development of synergy in spastic group of muscle. This synergy helps in developing a voluntary movt . Asso . Reaction – movt of sound extremity causes movt of affected extremity. E.g - Flexion of normal upper extremity causes movt of flexion of affected limb. 4/10/18 Brunnstrom approach 6

7. Basic limb synergies Mass movement patterns in response to stimulus or voluntary effort or both Gross flexor movement ( flexor synergy ) Gross extensor movement ( extensor synergy ) Combination of the strongest components of the synergies ( mixed synergy ) Appear during the early spastic period of recovery 4/10/18 7 Brunnstrom approach

8. Aim – development of synergy pattern in spastic muscle & once it devloped then break the synergy. Synergy pattern for upper limb – UL flexion – scapula retraction , shoulder abduction+ external rotation, elbow flexion, forearm supination , wrist & finger flexion. UL extention - Scapula protraction, shoulder adduction+ int. rotation, elbow extension, forearm pronation , wrist & finger flexion. 4/10/18 Brunnstrom approach 8

9. Basic limb synergies: UE 4/10/18 9 Brunnstrom approach

10. Basic limb synergies: LE 4/10/18 10 Brunnstrom approach

11. Extensor Flexor Mixed synergy: UE 4/10/18 11 Brunnstrom approach

12. The Typical Hemiplegic Posture HEAD Lateral y flexed toward the affected side UPPER LIMB Scapula – depressed, retracted Shoulder – adducted, IR Elbow – flexed Forearm – pronated Wrist – flexed, ulnarly deviated Fingers - flexed TRUNK Lateraly flexed toward the affected side LOWER LIMB Pelvis – posteriorly elevated, retracted Hip – IR, adducted, extended Knee – extended Ankle – plantarflexed , inverted, supinated Toes - flexed 4/10/18 12 Brunnstrom approach

13. Attitudinal and postural reflexes Tonic Neck Reflexes Symmetric TNR Asymmetric TNR stimulus response Neck flexion Upper extremity flexion Lower extremity extension Neck extension Upper extremity extension Lower extremity flexion stimulus response Neck lateral rotation Jaw side: upper extremity extension lower extremity extension Skull side: upper extremity flexion lower extremity flexion 4/10/18 13 Brunnstrom approach

14. Tonic Labyrinthine Reflexes Tonic Lumbar Reflex Attitudinal & postural reflexes stimulus response supine Limbs tend to move in extension prone Limbs tend to move in flexion stimulus response Trunk rotation (R) Increased flexor tone (R) UE and (L) LE Increased extensor tone (L) UE and (R) LE Trunk rotation (L) Increased flexor tone (L) UE and (R) LE Increased extensor tone (R) UE and (L) LE 4/10/18 14 Brunnstrom approach

15. Associated reactions Homolateral Limb Synkinesis The response of one extremity to stimulus will elicit the same response in its ipsilateral extremity Raimiste’s Phenomenon Resisted abduction or adduction of the sound limb evokes a similar response in the affected limb 4/10/18 15 Brunnstrom approach

16. Associated reactions Yawning Flexor synergy is elicited during initiation of yawn Coughing and Sneezing Evoke sudden muscular contractions of short duration 4/10/18 16 Brunnstrom approach

17. Hand reactions Instinctive Grasp Reaction Stationary contact with the palm of the hand results to closure of the hand Instinctive Avoiding Reaction With the arm elevated in a forward-upward direction, the fingers and thumb hyperextend; stroking the palm in a distal direction exaggerates the posture Souque’s Finger Phenomenon Elevation of the hemiplegic arm beyond the horizontal results to extension and abduction of the fingers

18. Recovery stages in hemiplegia STAGE CHARACTERISTICS Stage 1 Period of flaccidity Neither reflex nor voluntary movements are present Stage 2 Basic limb synergies may appear as associated reactions Spasticity begins mostly evident in strong components (flexor synergy appear prior to extensor synergy) Minimal voluntary movement responses may be present Stage 3 Patient starts to gain voluntary control over movement synergies Spasticity reaches its peak Semi-voluntary stage as individual is able to initiate movement but unable to control it 4/10/18 18 Brunnstrom approach

19. Recovery stages in hemiplegia STAGE CHARACTERISTICS Stage 4 Some movement combinations outside the path of basic limb synergy patterns are mastered Spasticity begins to decline Stage 5 More difficult combinations are mastered Spasticity continues to decline Stage 6 Individual joint movement becomes possible Coordination approaches normaly Spasticity disappears: individual is more capable of full movement patterns Stage 7 Normal motor functions are restored 4/10/18 19 Brunnstrom approach

20. Treatment Principles Treatment progress developmentally 2. When no motion exists, movement is facilitated using reflexes, associated reactions, proprioceptive facilitation and or exteroceptive facilitation to develop muscle tension in preparation for voluntary movement 4/10/18 20 Brunnstrom approach

21. Treatment Principles 3. Resistance ( proprioceptive stimulus) promotes a spread of impulses to produce a patterned response while tactile stimulation facilitates only the muscle related to the stimulated area 4/10/18 21 Brunnstrom approach

22. Treatment Principles 4. When voluntary effort produces or contribute to a response, patient is asked to hold the contraction (isometric). If successful, an eccentric (contracted lengthening) is performed and finally a concentric (shortening) contraction is done. 4/10/18 22 Brunnstrom approach

23. Treatment Principles 5. Facilitation is reduced or dropped out as quickly as the patient shows evidence of volitional control. 6. Correct movement once elicited is repeated 4/10/18 23 Brunnstrom approach

24. Treatment Bed posture Bed exercises (PROM,AAROM-AROM, Balance- Sitting) Hand training Trunk rotation Standing & walking Assisted walking Independent walking Obstacle walking Stair climbing 4/10/18 24 Brunnstrom approach

25. THANK YOU……. 4/10/18 25 Brunnstrom approach