BRUNNSTROM_S_MOVEMENT_THERAPY neurology.pdf
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Oct 07, 2024
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About This Presentation
Neurological rehabilitation
Slide Content
INSTROM’S MOVEMENT
THERAPY
THERAPY
Pthomegroup
Learning Objectives:
Understand the concept that underlies Movement
Therapy for stroke patients.
Demonstrate different reflexes including stimulus
and muscle tone response.
List the four aspects of movement control that are
assessed in Brunnstrom approach and discuss the
methods of evaluating them.
Discuss the Brunnstrom stages of recovery for
upper limb and lower limb.
Understand the treatment principle of this
approach.
Understand the treatment procedures for
facilitating movement in the trunk, upper extremity
and lower extremity using this approach.
Learning Objectives:
Understand the concept that underlies Movement
Therapy for stroke patients.
Demonstrate different reflexes including stimulus
and muscle tone response.
List the four aspects of movement control that are
assessed in Brunnstrom approach and discuss the
methods of evaluating them.
Discuss the Brunnstrom stages of recovery for
upper limb and lower limb.
Understand the treatment principle of this
approach.
Understand the treatment procedures for
facilitating movement in the trunk, upper extremity
and lower extremity using this approach.
thomegrot
HISTORY
© Developed for hemiplegic patients by
Signe Brunnstrom, a physical therapist
from Sweden.
e This approach was conceptualized from
the theory of reflex control and
hierarchial control.
© Stroke patients undergo “Development
in reverse” , so the early reflexive
movements should be seen as normal
process of development.
HISTORY
© Developed for hemiplegic patients by
Signe Brunnstrom, a physical therapist
from Sweden.
e This approach was conceptualized from
the theory of reflex control and
hierarchial control.
© Stroke patients undergo “Development
in reverse” , so the early reflexive
movements should be seen as normal
process of development.
Pit
PRINCIPLES
In normal motor development, spinal cord and
brainstem reflexes become modified and their
components rearrange into purposeful movement
through the influence of higher centers.
Proprioceptive and exteroceptive stimuli can be
used to evoke desired motion or tonal changes.
Recovery of voluntary movements post stroke
follows a mass to discrete pattern.
a produced, correct motions must be practiced
to be learned.
Practice within the context of daily activities
enhances the learning process.
Afferent innervation / sensation is necessary for
production of effective movement.
PRINCIPLES
In normal motor development, spinal cord and
brainstem reflexes become modified and their
components rearrange into purposeful movement
through the influence of higher centers.
Proprioceptive and exteroceptive stimuli can be
used to evoke desired motion or tonal changes.
Recovery of voluntary movements post stroke
follows a mass to discrete pattern.
a produced, correct motions must be practiced
to be learned.
Practice within the context of daily activities
enhances the learning process.
Afferent innervation / sensation is necessary for
production of effective movement.
Pthomegroup
BASIC LIMB SYNERGIES
© Mass movement patterns which are
stereotypic in response to stimulus or
voluntary effort or both
e Gross flexor movement ( )
e Gross extensor movement ( )
e Combination of the strongest components of the
synergies ( )
© Appear during the early spastic period of
recovery
BASIC LIMB SYNERGIES
© Mass movement patterns which are
stereotypic in response to stimulus or
voluntary effort or both
e Gross flexor movement ( )
e Gross extensor movement ( )
e Combination of the strongest components of the
synergies ( )
© Appear during the early spastic period of
recovery
LIMB SYNERGIES IMPORTANT!!
© Muscles are neurophysiologically linked
and cannot act alone or perform all of
their functions.
© If one muscle in the synergy is activated,
each muscle in the synergy responds
partially or completely.
© Patient CANNOT perform isolated
movements when bound by these
synergies.
© Muscles are neurophysiologically linked
and cannot act alone or perform all of
their functions.
© If one muscle in the synergy is activated,
each muscle in the synergy responds
partially or completely.
© Patient CANNOT perform isolated
movements when bound by these
synergies.
BASIC LIMB SYNERGY : UPPER LIMB
+ Scapula: retraction
and/or elevation
AIS |. Shoulder: abduction and
Synergy ext rotation
flexion
supination
+ Scapula: protraction and
/or depression
SEL is Shoulder: adduction and
Svner int rotation
ynergy « Elbow: extension
« Forearm: pronation
+ Scapula: retraction
and/or elevation
AIS |. Shoulder: abduction and
Synergy ext rotation
flexion
supination
+ Scapula: protraction and
/or depression
SEL is Shoulder: adduction and
Svner int rotation
ynergy « Elbow: extension
« Forearm: pronation
BASIC LIMB SYNERGY: LOWER LIMB
flexion,
abduction, and
Flexor ext rotation
Synergy : flexion
extension,
adduction, and
Extensor int rotation
extension
plantarflexion, inversion
flexion
Synergy
flexion,
abduction, and
Flexor ext rotation
Synergy : flexion
extension,
adduction, and
Extensor int rotation
extension
plantarflexion, inversion
flexion
Synergy
MIXED SYNERGY: UPPER LIMB
Strongest elbow flexion shoulder adduction
internal rotation
So)
1
——_
Strongest elbow flexion shoulder adduction
internal rotation
So)
1
——_
MIXED SYNERGY: LOWER LIMB
Strongest hip flexion hip adduction
knee extension
ankle plantarflexion
ankle inversion
Strongest hip flexion hip adduction
knee extension
ankle plantarflexion
ankle inversion
TYPICAL HEMIPLEGIC POSTURE
UPPER LIMB
TRUNK
LOWER LIMB
Scapula — depressed, retracted
Shoulder — adducted, IR
Elbow - flexed
Forearm — pronated
Wrist — flexed, ulnarly deviated
Fingers - flexed
Lateraly flexed toward the affected side
Pelvis — posteriorly elevated, retracted
Hip — IR, adducted, extended
Knee — extended
Ankle — plantarflexed, inverted, supinated
Toes - flexed
UPPER LIMB
TRUNK
LOWER LIMB
Scapula — depressed, retracted
Shoulder — adducted, IR
Elbow - flexed
Forearm — pronated
Wrist — flexed, ulnarly deviated
Fingers - flexed
Lateraly flexed toward the affected side
Pelvis — posteriorly elevated, retracted
Hip — IR, adducted, extended
Knee — extended
Ankle — plantarflexed, inverted, supinated
Toes - flexed
POSTURAL REFLEXES
© Tonic Neck Reflexes
e Symmetric TNR
stimulus response
Neck flexion Upper extremity flexion
Lower extremity extension
Neck extension Upper extremity extension
Lower extremity flexion
e Asymmetric TNR
stimulus response
Neck lateral Jaw side:
rotation upper extremity extension
lower extremity flexion
Skull side:
upper extremity flexion
lower extremity extension
© Tonic Neck Reflexes
e Symmetric TNR
stimulus response
Neck flexion Upper extremity flexion
Lower extremity extension
Neck extension Upper extremity extension
Lower extremity flexion
e Asymmetric TNR
stimulus response
Neck lateral Jaw side:
rotation upper extremity extension
lower extremity flexion
Skull side:
upper extremity flexion
lower extremity extension
POSTURAL REFLEXES
e Tonic Labyrinthine Reflexes
es
© Tonic Lumbar Reflex
e Tonic Labyrinthine Reflexes
es
© Tonic Lumbar Reflex
Pthomegroup
ASSOCIATED REACTIONS
© Associated reactions are automatic responses of
the involved limb resulting from action occurring
in some other part of the body, either by voluntary
or reflex stimulation (e.g., resistance or ATNR).
© They are commonly elicited when some degree of
spasticity is present and are infrequently seen in
a limb exhibiting minimal muscle tone.
© May occur in the affected limb under a variety of
condition: in the presence of spasticity, when a
degree of voluntary control has been achieved,
and after spasticity has subsided.
© May be present years after the onset of
hemiplegia.
ASSOCIATED REACTIONS
© Associated reactions are automatic responses of
the involved limb resulting from action occurring
in some other part of the body, either by voluntary
or reflex stimulation (e.g., resistance or ATNR).
© They are commonly elicited when some degree of
spasticity is present and are infrequently seen in
a limb exhibiting minimal muscle tone.
© May occur in the affected limb under a variety of
condition: in the presence of spasticity, when a
degree of voluntary control has been achieved,
and after spasticity has subsided.
© May be present years after the onset of
hemiplegia.
ASSOCIATED REACTIONS
© Observations by Brunnstrom 1951,1952)
° repeated stimuli may be required to evoke a
response.
e tension in the muscles of the affected limb
persists even after cessation of stimulus that
evoked the associated reaction.
+ attitudinal reflexes influence the outcome of
associated reactions
© Observations by Brunnstrom 1951,1952)
° repeated stimuli may be required to evoke a
response.
e tension in the muscles of the affected limb
persists even after cessation of stimulus that
evoked the associated reaction.
+ attitudinal reflexes influence the outcome of
associated reactions
ASSOCIATED REACTIONS
© Homolateral Limb Synkinesis
e The response of one extremity to stimulus
will elicit the same response in its
ipsilateral extremity.
© Raimiste’s Phenomenon
e Resisted abduction or adduction of the
sound limb evokes a similar response in
the affected limb.
© Homolateral Limb Synkinesis
e The response of one extremity to stimulus
will elicit the same response in its
ipsilateral extremity.
© Raimiste’s Phenomenon
e Resisted abduction or adduction of the
sound limb evokes a similar response in
the affected limb.
homegroup
ASSOCIATED REACTIONS
© Yawning
e Flexor synergy is elicited during initiation of
yawn
e Coughing and Sneezing
e Evoke sudden muscular contractions of
short duration
ASSOCIATED REACTIONS
© Yawning
e Flexor synergy is elicited during initiation of
yawn
e Coughing and Sneezing
e Evoke sudden muscular contractions of
short duration
RECOVERY STAGES IN
HEMIPLEGIA
Sy AS
«Period of flaccidity
«Neither reflex nor voluntary movements are present
«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
«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
HEMIPLEGIA
Sy AS
«Period of flaccidity
«Neither reflex nor voluntary movements are present
«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
«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
RECOVERY STAGES IN HEMIPLEGIA
ere
Some movement combinations outside the path
of basic limb synergy patterns are mastered
*Spasticity begins to decline
«Individual joint movement becomes possible
*Coordination approaches normalcy
*Spasticity disappears: individual is more capable
of full movement patterns
Normal motor functions are restored
«More difficult combinations are mastered
*Spasticity continues to decline
ere
Some movement combinations outside the path
of basic limb synergy patterns are mastered
*Spasticity begins to decline
«Individual joint movement becomes possible
*Coordination approaches normalcy
*Spasticity disappears: individual is more capable
of full movement patterns
Normal motor functions are restored
«More difficult combinations are mastered
*Spasticity continues to decline
BRUNNSTROM EVALUATION
© Evaluation in the Brunnstrom approach
includes determination of the following:
1. The patient's sensory status.
2. The level of recovery of voluntary motor
control;
3. The effect of tonic reflexes on the patient's
movement;
4. The effect of associated reactions on the
patient's movement.
© Evaluation in the Brunnstrom approach
includes determination of the following:
1. The patient's sensory status.
2. The level of recovery of voluntary motor
control;
3. The effect of tonic reflexes on the patient's
movement;
4. The effect of associated reactions on the
patient's movement.
SENSORY EVALUATION
e The sensory evaluation precedes the motor
evaluation.
1. Touch evaluation including tactile
localisation
2. Joint position sense
© Results of the sensory evaluation guide
choice of facilitation modalities that the
therapist may use to facilitate movement
e The sensory evaluation precedes the motor
evaluation.
1. Touch evaluation including tactile
localisation
2. Joint position sense
© Results of the sensory evaluation guide
choice of facilitation modalities that the
therapist may use to facilitate movement
LEVEL OF RECOVERY OF
VOLUNTARY MOVEMENTS
o Brunnstrom listed six stages of recovery
for the arm, hand and leg movements.
e Although stroke patients, on average,
proceed through these stages, a particular
patient may stop at any stage.
© To date, there are no reliable ways to
predict which patients will recover voluntary
movement and which will not.
VOLUNTARY MOVEMENTS
o Brunnstrom listed six stages of recovery
for the arm, hand and leg movements.
e Although stroke patients, on average,
proceed through these stages, a particular
patient may stop at any stage.
© To date, there are no reliable ways to
predict which patients will recover voluntary
movement and which will not.
EST ECC
Flaccidity Flaccidity-no Flaccidity
voluntary
movement
Spasticity develops, minimal Synergies Little or no active
voluntary movements developing-flexion finger flexion
usually develops
before extension
Spasticity
developing
Spasticity peaks, flexion Beginning Mass grasp or
and extension synergy voluntary hook grasp No
present movement, but voluntary finger
only in synergy; extension or
increased release
spasticity, which
may become
marked
Flaccidity Flaccidity-no Flaccidity
voluntary
movement
Spasticity develops, minimal Synergies Little or no active
voluntary movements developing-flexion finger flexion
usually develops
before extension
Spasticity
developing
Spasticity peaks, flexion Beginning Mass grasp or
and extension synergy voluntary hook grasp No
present movement, but voluntary finger
only in synergy; extension or
increased release
spasticity, which
may become
marked
LEG
Knee flexion past 90
degrees in sitting with
foot sliding backwards.
Dorsiflexion at ankle
possible.
Knee flexion with hip
extension possible.
Ankle dorsiflexion with
hip and knee
extended.
Hip abduction in sitting
and standing possible.
Ankle eversion
possible.
Some movements deviating from
synergy;
a. Hand behind body;
b. Arm to forward-horizontol
position;
c. Pronation-supination with elbow
flexed to 90"; spasticity decreasing.
Independence from the basic
synergies:
a. Arm to side-horizontal position;
b. Arm forward and overhead;
c. Pronation-supination with elbow
full extended; spasticity weaning
Isolated joint movements freely
performed with near normal
coordination; spasticity minimal
Lateral prehension
with release by thumb
movement
Semivoluntary finger
extension
Palmar prehension
Cylindrical and
spherical grasp
(awkward )
Voluntary mass finger
extension (variable
range of motion)
All types of
prehension (improved
skill) Voluntary finger
extension (full range
of motion) Individual
finger movements
Knee flexion past 90
degrees in sitting with
foot sliding backwards.
Dorsiflexion at ankle
possible.
Knee flexion with hip
extension possible.
Ankle dorsiflexion with
hip and knee
extended.
Hip abduction in sitting
and standing possible.
Ankle eversion
possible.
Some movements deviating from
synergy;
a. Hand behind body;
b. Arm to forward-horizontol
position;
c. Pronation-supination with elbow
flexed to 90"; spasticity decreasing.
Independence from the basic
synergies:
a. Arm to side-horizontal position;
b. Arm forward and overhead;
c. Pronation-supination with elbow
full extended; spasticity weaning
Isolated joint movements freely
performed with near normal
coordination; spasticity minimal
Lateral prehension
with release by thumb
movement
Semivoluntary finger
extension
Palmar prehension
Cylindrical and
spherical grasp
(awkward )
Voluntary mass finger
extension (variable
range of motion)
All types of
prehension (improved
skill) Voluntary finger
extension (full range
of motion) Individual
finger movements
IMPORTANT INSTRUCTIONS
© Make the patient physically and psychologically
comfortable.
© The sequential aspects of the motor evaluation are used
to determine the patient's level of motor control.
e No movements beyond the patient's capabilities are
demanded.
© No facilitation is used during the evaluation.
© Each motion is demonstrated to the patient, and he does
it with his unaffected extremity before he attempts it with
his affected one.
o Instructions should be given in functional terms. For
exam le, to test the flexor Ee of the upper extremity,
say ' "Touch behind your ear" and for the extension
FAR y, "Reach out to touch your [opposite] knee"
runnstrom, 1966)
© Make the patient physically and psychologically
comfortable.
© The sequential aspects of the motor evaluation are used
to determine the patient's level of motor control.
e No movements beyond the patient's capabilities are
demanded.
© No facilitation is used during the evaluation.
© Each motion is demonstrated to the patient, and he does
it with his unaffected extremity before he attempts it with
his affected one.
o Instructions should be given in functional terms. For
exam le, to test the flexor Ee of the upper extremity,
say ' "Touch behind your ear" and for the extension
FAR y, "Reach out to touch your [opposite] knee"
runnstrom, 1966)
thomegrot
TONIC REFLEXES
e Tonic reflexes are assessed to
determine whether they can be used in
early treatment to initiate movement
when none exists.
© The primitive reflexes that may be
present include the symmetrical and
asymmetrical tonic neck reflexes, tonic
labyrinthine reflexes, and tonic lumbar
reflexes.
TONIC REFLEXES
e Tonic reflexes are assessed to
determine whether they can be used in
early treatment to initiate movement
when none exists.
© The primitive reflexes that may be
present include the symmetrical and
asymmetrical tonic neck reflexes, tonic
labyrinthine reflexes, and tonic lumbar
reflexes.
ASSOCIATED REACTIONS
© Associated reactions are evaluated to
determine which could be used to
facilitate movement when no voluntary
movement exists.
© They are more easily elicited when
spasticity is present.
© Associated reactions are evaluated to
determine which could be used to
facilitate movement when no voluntary
movement exists.
© They are more easily elicited when
spasticity is present.
Pthomegroup
ASSOCIATED REACTIONS
© Flexor synergy in the involved upper
extremity is elicited by applying resistance
to shoulder elevation or elbow flexion of the
noninvolved upper extremity.
© Extensor synergy in the involved upper
extremity is elicited by applying resistance
to horizontal adduction of the noninvolved
upper extremity, which is equivalent to
Raimiste's phenomenon.
ASSOCIATED REACTIONS
© Flexor synergy in the involved upper
extremity is elicited by applying resistance
to shoulder elevation or elbow flexion of the
noninvolved upper extremity.
© Extensor synergy in the involved upper
extremity is elicited by applying resistance
to horizontal adduction of the noninvolved
upper extremity, which is equivalent to
Raimiste's phenomenon.
thomegrot
ASSOCIATED REACTIONS
© Raimiste's phenomena are associated
reactions of hip abduction or adduction.
© Resistance to hip abduction or adduction of
the non-involved extremity evokes the same
motion of the involved extremity.
© Resistance to flexion of the noninvolved leg
causes extension of the involved extremity,
and resistance to extension of the
noninvolved side causes flexion of the
involved extremity.
ASSOCIATED REACTIONS
© Raimiste's phenomena are associated
reactions of hip abduction or adduction.
© Resistance to hip abduction or adduction of
the non-involved extremity evokes the same
motion of the involved extremity.
© Resistance to flexion of the noninvolved leg
causes extension of the involved extremity,
and resistance to extension of the
noninvolved side causes flexion of the
involved extremity.
ASSOCIATED REACTIONS
© Resisted grasp by the non-involved hand
causes a grasp reaction in the involved hand.
© Flexor movement or tone may be elicited in
the involved arm when the patient attempts to
flex the leg or when leg flexion is resisted.
This reaction is called homolateral synkinesis.
© Resisted grasp by the non-involved hand
causes a grasp reaction in the involved hand.
© Flexor movement or tone may be elicited in
the involved arm when the patient attempts to
flex the leg or when leg flexion is resisted.
This reaction is called homolateral synkinesis.
BRUNNSTOM THERAPY
PRINCIPLES
Facilitate the patient's progress
throughout the recovery stages.
©Use of postural and attitudinal reflexes
to increase and decrease tone of
muscles.
©Stimulation of skin over the muscle
produces contraction.
oResistance facilitates contraction .
PRINCIPLES
Facilitate the patient's progress
throughout the recovery stages.
©Use of postural and attitudinal reflexes
to increase and decrease tone of
muscles.
©Stimulation of skin over the muscle
produces contraction.
oResistance facilitates contraction .
thomegrot
TREATMENT
© The focus of treatment is the
recapitulation of normal movement
developmentally from its reflexive base
to voluntary control of individual motions
that can be used functionally.
TREATMENT
© The focus of treatment is the
recapitulation of normal movement
developmentally from its reflexive base
to voluntary control of individual motions
that can be used functionally.
REHABILITATING TRUNK CONTROL
© Some patients with hemiplegia may
have poor trunk control and may require
training to enable them to bend over to
retrieve an object from the floor or to
dress their lower extremities.
© To elicit balance responses, the patient
is gently pushed in forward, backward,
and side-to-side directions.
© Some patients with hemiplegia may
have poor trunk control and may require
training to enable them to bend over to
retrieve an object from the floor or to
dress their lower extremities.
© To elicit balance responses, the patient
is gently pushed in forward, backward,
and side-to-side directions.
REHABILITATING TRUNK CONTROL
© At first, emphasis is given to promoting
contraction of trunk muscles on the non-
involved side by pushing the patient off
balance toward the involved side while
guarding in case of poor response.
e once it is determined that the person
has that skill, recovery from a push
toward the noninvolved side is sought.
© At first, emphasis is given to promoting
contraction of trunk muscles on the non-
involved side by pushing the patient off
balance toward the involved side while
guarding in case of poor response.
e once it is determined that the person
has that skill, recovery from a push
toward the noninvolved side is sought.
REHABILITATING TRUNK CONTROL
© The patient is pushed only to the point at
which he is able to hold the position and
then regain upright posture and is
guarded throughout.
e Training then progresses to promote
trunk flexion, extension, and rotation.
© The patient is pushed only to the point at
which he is able to hold the position and
then regain upright posture and is
guarded throughout.
e Training then progresses to promote
trunk flexion, extension, and rotation.
TRAINING FORWARD FLEXION
© Practice in forward flexion of the trunk is assisted.
© The patient crosses his arms with the non-involved
hand under the involved elbow and the noninvolved
forearm supporting the involved forearm.
© The therapist, sitting facing the patient, supports the
patient under the elbows and assists in trunk flexion
forward, avoiding any pull on the shoulders.
© Some pain-free shoulder flexion is accomplished
during this forward movement.
© The patient is concentrating on trunk control, and
shoulder movement occurs without conscious
awareness.
© Return from trunk flexion is performed actively by
the patient.
© Practice in forward flexion of the trunk is assisted.
© The patient crosses his arms with the non-involved
hand under the involved elbow and the noninvolved
forearm supporting the involved forearm.
© The therapist, sitting facing the patient, supports the
patient under the elbows and assists in trunk flexion
forward, avoiding any pull on the shoulders.
© Some pain-free shoulder flexion is accomplished
during this forward movement.
© The patient is concentrating on trunk control, and
shoulder movement occurs without conscious
awareness.
© Return from trunk flexion is performed actively by
the patient.
TRAINING TRUNK FLEXION
e Then, while sitting without back support
and with the involved arm supported as
described before, the patient is pushed
backward and encouraged to regain
upright posture actively.
© Forward flexion in oblique directions is
then done not only to promote regaining
balance but also to incorporate more
scapular motion with the shoulder
flexion already achieved.
e Then, while sitting without back support
and with the involved arm supported as
described before, the patient is pushed
backward and encouraged to regain
upright posture actively.
© Forward flexion in oblique directions is
then done not only to promote regaining
balance but also to incorporate more
scapular motion with the shoulder
flexion already achieved.
TRAINING TRUNK ROTATION
o Trunk rotation is then practiced with the patient
supporting his involved arm and the therapist guiding
trunk motion.
© Trunk rotation can be combined with head
movements in the opposite direction of the trunk
rotation, so that the tonic neck and tonic lumbar
reflexes can be utilized as one way to begin to elicit
the shoulder components of the upper extremity
synergies.
© The arms and trunk move in one direction while the
head turns in the opposite direction. Head and trunk
movements are combined with increasing ranges of
movement of the shoulder, enabling pain-free
shoulder and scapular abduction and adduction to be
accomplished during trunk rotation.
o Trunk rotation is then practiced with the patient
supporting his involved arm and the therapist guiding
trunk motion.
© Trunk rotation can be combined with head
movements in the opposite direction of the trunk
rotation, so that the tonic neck and tonic lumbar
reflexes can be utilized as one way to begin to elicit
the shoulder components of the upper extremity
synergies.
© The arms and trunk move in one direction while the
head turns in the opposite direction. Head and trunk
movements are combined with increasing ranges of
movement of the shoulder, enabling pain-free
shoulder and scapular abduction and adduction to be
accomplished during trunk rotation.
RETRAINING PROXIMAL UPPER
EXTREMITY CONTROL (STAGES 1-3)
© The goal of treatment is to promote
voluntary control of the synergies and to
encourage their use in purposeful
activities.
© In these stages, all movements occur in
synergy patterns but with increasing
voluntary initiation and control of these
patterns.
EXTREMITY CONTROL (STAGES 1-3)
© The goal of treatment is to promote
voluntary control of the synergies and to
encourage their use in purposeful
activities.
© In these stages, all movements occur in
synergy patterns but with increasing
voluntary initiation and control of these
patterns.
RETRAINING PROXIMAL UPPER
EXTREMITY CONTROL (STAGES 1-3)
e To move the patient from stage | (flaccidity) to
stage 2 (beginning synergy), the basic limb
synergies are elicited at a reflex level, using
as many reflexes, associated reactions, and
facilitation procedures as are necessary to
elicit a response.
© The patient tries to move (willed movement)
as these facilitation techniques are used.
EXTREMITY CONTROL (STAGES 1-3)
e To move the patient from stage | (flaccidity) to
stage 2 (beginning synergy), the basic limb
synergies are elicited at a reflex level, using
as many reflexes, associated reactions, and
facilitation procedures as are necessary to
elicit a response.
© The patient tries to move (willed movement)
as these facilitation techniques are used.
FLEXOR SYNERGY TRAINING
© The flexor synergy is the first to develop.
Within that synergy, the strongest
component, elbow flexion, is the first motion
to be elicited.
© Once elbow flexion is seen, the therapist
turns concentration from elbow flexion to the
proximal components of the synergy with the
goal of enabling the patient to "capture the
synergy," i.e., bring it under voluntary control
(stage 3).
© The flexor synergy is the first to develop.
Within that synergy, the strongest
component, elbow flexion, is the first motion
to be elicited.
© Once elbow flexion is seen, the therapist
turns concentration from elbow flexion to the
proximal components of the synergy with the
goal of enabling the patient to "capture the
synergy," i.e., bring it under voluntary control
(stage 3).
TRAINING SCAPULAR ELEVATION
© Efforts to achieve voluntary control of the
flexor synergy begin with scapular elevation.
© Lateral flexion of the neck toward the involved
side can be used to initiate scapular elevation
because the upper trapezius does both
motions although it may have "forgotten" how
to elevate the scapula.
© Efforts to achieve voluntary control of the
flexor synergy begin with scapular elevation.
© Lateral flexion of the neck toward the involved
side can be used to initiate scapular elevation
because the upper trapezius does both
motions although it may have "forgotten" how
to elevate the scapula.
TRAINING SCAPULAR ELEVATION
© With the patient's arm supported on a table in
shoulder abduction with elbow flexion, resistance
is given simultaneously to the head and shoulder
while the patient is asked to "hold" the head and
not let it be moved away from the shoulder.
© Once elevation begins, active contraction may be
promoted by an associated reaction. For
example, as the patient attempts bilateral
scapular elevation, resistance is given to the
non-involved scapula.
© With the patient's arm supported on a table in
shoulder abduction with elbow flexion, resistance
is given simultaneously to the head and shoulder
while the patient is asked to "hold" the head and
not let it be moved away from the shoulder.
© Once elevation begins, active contraction may be
promoted by an associated reaction. For
example, as the patient attempts bilateral
scapular elevation, resistance is given to the
non-involved scapula.
TRAINING SCAPULAR ELEVATION
o If the involved scapula elevates as a result of an
associated reaction, resistance is then added on the
involved side as the patient is asked to "hold."
© Unilateral scapular elevation of the involved arm is
attempted next and may be achieved as a result of
the previous procedures.
© Ifthe patient is unable to accomplish the motion,
the therapist supports the patient's arm and assists
the patient to elevate the scapula. Percussion or
stroking over the upper trapezius will facilitate
muscle contraction.
o If the involved scapula elevates as a result of an
associated reaction, resistance is then added on the
involved side as the patient is asked to "hold."
© Unilateral scapular elevation of the involved arm is
attempted next and may be achieved as a result of
the previous procedures.
© Ifthe patient is unable to accomplish the motion,
the therapist supports the patient's arm and assists
the patient to elevate the scapula. Percussion or
stroking over the upper trapezius will facilitate
muscle contraction.
SCAPULAR ELEVATION INHIBITS
PECTORALIS MAJOR
© The patient is then told to hold, "Don't let me
push your shoulder down." After repeated
holding with some resistance added, the
patient does an eccentric contraction-lets the
shoulder down slowly.
© Then a concentric, or shortening, contraction is
attempted when the person is told, "Now pull
your shoulder up toward your ear.” Active
scapular elevation evokes other flexor
components and tends to inhibit the pectoralis
major.
PECTORALIS MAJOR
© The patient is then told to hold, "Don't let me
push your shoulder down." After repeated
holding with some resistance added, the
patient does an eccentric contraction-lets the
shoulder down slowly.
© Then a concentric, or shortening, contraction is
attempted when the person is told, "Now pull
your shoulder up toward your ear.” Active
scapular elevation evokes other flexor
components and tends to inhibit the pectoralis
major.
TRAINING SHOULDER ABDUCTION
WITH SCAPULAR ELEVATION
© The patient repeats scapular elevation and
relaxation as the therapist gently abducts the
shoulder in increasing increments.
© Because many patients with hemiplegia
experience shoulder pain and/or have
shoulder subluxation, the shoulder is given
special care, and the correct scapulohumeral
orientation is maintained.
WITH SCAPULAR ELEVATION
© The patient repeats scapular elevation and
relaxation as the therapist gently abducts the
shoulder in increasing increments.
© Because many patients with hemiplegia
experience shoulder pain and/or have
shoulder subluxation, the shoulder is given
special care, and the correct scapulohumeral
orientation is maintained.
WORKING ON SHOULDER EXTERNAL
ROTATION AND FOREARM
SUPINATION
© Once shoulder elevation and some active
abduction have been achieved, external
rotation and forearm supination are then
included in the movement.
© Reversal of movements into the opposite
direction are done from the start and this
begins to develop some components of the
extensor synergy.
ROTATION AND FOREARM
SUPINATION
© Once shoulder elevation and some active
abduction have been achieved, external
rotation and forearm supination are then
included in the movement.
© Reversal of movements into the opposite
direction are done from the start and this
begins to develop some components of the
extensor synergy.
WORKING ON EXTENSOR
SYNERGY (P. MAJOR)
© The extensor synergy tends to follow the :flexor
synergy and may need to be assisted in its initiation.
e Contraction of the pectoralis major, a strong
component of the extensor synergy, can be elicited by
the associated reaction in which the therapist
supports the patient's arms in a position between
horizontal abduction and adduction, instructs the
patient to bring his arms together, and resists the
noninvolved arm just proximal to the elbow.
o As contraction occurs bilaterally the patient is
instructed, "Don't let me pull your arms apart." Then
he attempts to bring his arms together voluntarily.
SYNERGY (P. MAJOR)
© The extensor synergy tends to follow the :flexor
synergy and may need to be assisted in its initiation.
e Contraction of the pectoralis major, a strong
component of the extensor synergy, can be elicited by
the associated reaction in which the therapist
supports the patient's arms in a position between
horizontal abduction and adduction, instructs the
patient to bring his arms together, and resists the
noninvolved arm just proximal to the elbow.
o As contraction occurs bilaterally the patient is
instructed, "Don't let me pull your arms apart." Then
he attempts to bring his arms together voluntarily.
WORKING ON ELBOW EXTENSORS
© Because of the predominance of excess tone
in the elbow flexors and relative weakness of
elbow extensors, elbow extension is usually
more difficult to obtain.
o Bilateral "rowing" is the procedure used to
initiate elbow extension. In the rowing
procedure, movements toward extension
combined with pronation are resisted and
movements into flexion combined with
supination are guided .
© Because of the predominance of excess tone
in the elbow flexors and relative weakness of
elbow extensors, elbow extension is usually
more difficult to obtain.
o Bilateral "rowing" is the procedure used to
initiate elbow extension. In the rowing
procedure, movements toward extension
combined with pronation are resisted and
movements into flexion combined with
supination are guided .
THE “ROWING TECHNIQUE”
© Rowing is done with the therapist and patient
seated facing each other; the therapist's arms
are crossed so that she and the patient grasp
right hand to right hand and left hand to left
hand.
o First, elbow extension is elicited as an
associated reaction by resisting the non involved
arm as it moves into extension and assisting the
involved arm into extension toward the non
involved knee.
Once the affected limb is felt to contract,
resistance is offered ‘bilaterally.
©
© Rowing is done with the therapist and patient
seated facing each other; the therapist's arms
are crossed so that she and the patient grasp
right hand to right hand and left hand to left
hand.
o First, elbow extension is elicited as an
associated reaction by resisting the non involved
arm as it moves into extension and assisting the
involved arm into extension toward the non
involved knee.
Once the affected limb is felt to contract,
resistance is offered ‘bilaterally.
©
“HOLD AFTER POSITIONING”
© "Hold after positioning” is used to reinforce
voluntary effort.
© When the patient's arm is positioned in
extension synergy with the elbow in nearly
full extension, he is asked to "hold" against
resistance.
© To facilitate the extensors, quick stretches
are applied to the involved arm by lightly
pushing back toward elbow flexion.
© "Hold after positioning” is used to reinforce
voluntary effort.
© When the patient's arm is positioned in
extension synergy with the elbow in nearly
full extension, he is asked to "hold" against
resistance.
© To facilitate the extensors, quick stretches
are applied to the involved arm by lightly
pushing back toward elbow flexion.
BILATERAL WEIGHT BEARING TO
FACILITATE EXTENSOR SYNERGY
© When the extensor pine | is seen to come under
active control, it is further developed through use of
bilateral weight bearing.
© The patient leans forward onto his extended arms
supported by a low stool placed in front of him.
© The patient uses the non-involved hand to position
the involved hand on a sandbag, pillow, or towel
placed on the stool.
© Vigorous stroking of the skin over the triceps or _
tapping is done as the patient attempts to bear his
weight on both outstretched arms.
© Once he is successful, weight is shifted so that the
involved extremity attempts to support the weight of
the upper trunk.
FACILITATE EXTENSOR SYNERGY
© When the extensor pine | is seen to come under
active control, it is further developed through use of
bilateral weight bearing.
© The patient leans forward onto his extended arms
supported by a low stool placed in front of him.
© The patient uses the non-involved hand to position
the involved hand on a sandbag, pillow, or towel
placed on the stool.
© Vigorous stroking of the skin over the triceps or _
tapping is done as the patient attempts to bear his
weight on both outstretched arms.
© Once he is successful, weight is shifted so that the
involved extremity attempts to support the weight of
the upper trunk.
Pthomegroup
PROGRESSION TO UNILATERAL
WEIGHT BEARING
© Unilateral weight bearing can be used
functionally to hold objects while they are
being worked on by the other hand.
e e. g., holding a piece of wood while sawing,
hammering, or painting it; holding a package
steady while opening it, addressing it, or
fastening it; supporting body weight while
polishing or washing large surfaces such as a
table or floor.
PROGRESSION TO UNILATERAL
WEIGHT BEARING
© Unilateral weight bearing can be used
functionally to hold objects while they are
being worked on by the other hand.
e e. g., holding a piece of wood while sawing,
hammering, or painting it; holding a package
steady while opening it, addressing it, or
fastening it; supporting body weight while
polishing or washing large surfaces such as a
table or floor.
Pthomegroup
ENCOURAGING ACTIVE ELBOW
EXTENSION
e To encourage active elbow extension,
once the triceps is activated via -rowing
and weight bearing, unilateral resistance
is offered to the patient's attempts to
move into an extension pattern.
© Resistance gives direction to patient’s
effort and facilitates a stronger
contraction.
ENCOURAGING ACTIVE ELBOW
EXTENSION
e To encourage active elbow extension,
once the triceps is activated via -rowing
and weight bearing, unilateral resistance
is offered to the patient's attempts to
move into an extension pattern.
© Resistance gives direction to patient’s
effort and facilitates a stronger
contraction.
Pthomegroup
USING ATNR AND TLR TO
FACILITATE ELBOW EXTENSION
© Other means that may be used to facilitate
extension movement include use of supine
position (tonic labyrinthine reflex).
© Having the patient watch his extremity, which
requires head turning and pulls in the
asymmetrical tonic neck reflex.
© Working with the forearm pronated, which is a
strong component of the extensor synergy.
e Rotating the trunk toward the non-involved side
to facilitate extension of the involved arm via the
tonic lumbar reflex.
USING ATNR AND TLR TO
FACILITATE ELBOW EXTENSION
© Other means that may be used to facilitate
extension movement include use of supine
position (tonic labyrinthine reflex).
© Having the patient watch his extremity, which
requires head turning and pulls in the
asymmetrical tonic neck reflex.
© Working with the forearm pronated, which is a
strong component of the extensor synergy.
e Rotating the trunk toward the non-involved side
to facilitate extension of the involved arm via the
tonic lumbar reflex.
Pthomegroup
FUNCTIONAL USAGE OF BOTH
SYNERGIES
o As the synergies come under voluntary control, they
should be used in functional activities.
© The extensor synergy can be used to stabilize an
object to be worked on by the other side, to push
the arm into the sleeve of garments, to smooth out a
sheet on the bed, or to sponge off the kitchen
counter.
© The flexor synergy can be used functionally to
assist in carrying Items (such as a coat, handbag, or
briefcase), feeding oneself, or putting on glasses.
o Bilateral pushing na activities reinforce both
synergies. lroning and polishing are examples of
activities that use the flexor and extensor synergies
alternately and repeatedly.
FUNCTIONAL USAGE OF BOTH
SYNERGIES
o As the synergies come under voluntary control, they
should be used in functional activities.
© The extensor synergy can be used to stabilize an
object to be worked on by the other side, to push
the arm into the sleeve of garments, to smooth out a
sheet on the bed, or to sponge off the kitchen
counter.
© The flexor synergy can be used functionally to
assist in carrying Items (such as a coat, handbag, or
briefcase), feeding oneself, or putting on glasses.
o Bilateral pushing na activities reinforce both
synergies. lroning and polishing are examples of
activities that use the flexor and extensor synergies
alternately and repeatedly.
RETRAINING PROXIMAL UPPER
EXTREMITY CONTROL (STAGES 4-6)
© To promote movement deviating from
synergy, motions that begin to combine
components of synergies in small increments
are encouraged as a transition from stage 3 to
stage 4.
© For example, as the patient begins to extend
his arm consistently in response to the
unilateral resistance given by the therapist,
the therapist guides the direction of
movement toward shoulder abduction in
conjunction with elbow extension.
EXTREMITY CONTROL (STAGES 4-6)
© To promote movement deviating from
synergy, motions that begin to combine
components of synergies in small increments
are encouraged as a transition from stage 3 to
stage 4.
© For example, as the patient begins to extend
his arm consistently in response to the
unilateral resistance given by the therapist,
the therapist guides the direction of
movement toward shoulder abduction in
conjunction with elbow extension.
Pthomegroup
DISSOCIATING TRICEPS AND
PECTORALIS MAJOR
© This breaks up the synergistic
relationship of shoulder adduction to
elbow extension.
© The therapist requests the patient to
push his hand into her hand as she
directs the movement away from the
patient's midline.
© When the triceps and pectoralis major
are disassociated, the synergies no
longer dominate.
DISSOCIATING TRICEPS AND
PECTORALIS MAJOR
© This breaks up the synergistic
relationship of shoulder adduction to
elbow extension.
© The therapist requests the patient to
push his hand into her hand as she
directs the movement away from the
patient's midline.
© When the triceps and pectoralis major
are disassociated, the synergies no
longer dominate.
CONDITIONING THE SYNERGIES
© In stages 4 and 5 the goal of treatment is to condition
the synergies, i.e., to promote voluntary movement
that combines components of the two synergies into
increasingly varied combinations of movements that
deviate from synergy.
© Proprioceptive and exteroceptive stimuli are still used
in this phase of training, but tonic reflexes and
associated reactions, appropriate in the earlier stages
when reflex behavior was desirable, are no longer
used.
© Willed movement with isolated control of muscle
groups is the desired goal.
© In stages 4 and 5 the goal of treatment is to condition
the synergies, i.e., to promote voluntary movement
that combines components of the two synergies into
increasingly varied combinations of movements that
deviate from synergy.
© Proprioceptive and exteroceptive stimuli are still used
in this phase of training, but tonic reflexes and
associated reactions, appropriate in the earlier stages
when reflex behavior was desirable, are no longer
used.
© Willed movement with isolated control of muscle
groups is the desired goal.
Pthomegroup
SUBDUING STRONGER COMPONENTS
© The first out-of-synergy motion of stage 4 is
hand behind the body, which combines relative
shoulder abduction (flexor synergy) with elbow
extension and forearm pronation (extensor
synergy).
e This motion requires that the strongest
components of each synergy be subdued.
e To assist in getting the hand behind the body, a
swinging motion of the arm combined with trunk
rotation is helpful; if balance is good, this can be
done more easily when standing.
SUBDUING STRONGER COMPONENTS
© The first out-of-synergy motion of stage 4 is
hand behind the body, which combines relative
shoulder abduction (flexor synergy) with elbow
extension and forearm pronation (extensor
synergy).
e This motion requires that the strongest
components of each synergy be subdued.
e To assist in getting the hand behind the body, a
swinging motion of the arm combined with trunk
rotation is helpful; if balance is good, this can be
done more easily when standing.
SENSORY AWARENESS OF
MOVEMENT
© As the hand reaches the back of the patient,
he strokes the dorsum of the hand against the
body to complete the sensory awareness of
the movement.
© Stroking the dorsum of the hand on the back
is thought to give direction to the attempted
voluntary movement.
MOVEMENT
© As the hand reaches the back of the patient,
he strokes the dorsum of the hand against the
body to complete the sensory awareness of
the movement.
© Stroking the dorsum of the hand on the back
is thought to give direction to the attempted
voluntary movement.
PASSIVE ASSISTANCE BY THERAPIST
© If the patient is unable to do the full motion
actively, the therapist passively moves the
patient's arm into final position and stroke the
dorsum of the patient's hand against his
sacrum.
© The patient, while attempting to do the
movement himself, is then assisted into and
out of the pattern, which gradually becomes
voluntary with practice.
© If the patient is unable to do the full motion
actively, the therapist passively moves the
patient's arm into final position and stroke the
dorsum of the patient's hand against his
sacrum.
© The patient, while attempting to do the
movement himself, is then assisted into and
out of the pattern, which gradually becomes
voluntary with practice.
TASK ORIENTED PRACTICE
© Practice, using functional tasks as much as
possible, continues until the motion can be
freely accomplished.
© Examples of functional tasks, with the patient
standing, include putting a belt on, sorting
objects by moving certain objects from the
table and dropping them into a bucket placed
immediately behind the involved foot, and
tucking a shirt into trousers.
© Practice, using functional tasks as much as
possible, continues until the motion can be
freely accomplished.
© Examples of functional tasks, with the patient
standing, include putting a belt on, sorting
objects by moving certain objects from the
table and dropping them into a bucket placed
immediately behind the involved foot, and
tucking a shirt into trousers.
TRAINING FORWARD SHOULDER
FLEXION WITH ELBOW EXTENSION
The second out-of-synergy motion is shoulder flexion to a
forward-horizontal position with the elbow extended.
If the patient is unable actively to flex the shoulder forward,
even with the therapist providing local facilitation and
guidance of movement, then the arm is brought passively
into position.
While tapping over the anterior and middle deltoid muscles,
the therapist asks the patient to hold the position.
If hold after positioning is accomplished, active motion in
small increments is then sought starting with lowering of the
arm followed by active shoulder flexion.
Stroking and rubbing of the triceps are used to assist in
keeping the elbow straight as the arm is raised.
ie continues until the full forward flexion motion can be
one.
FLEXION WITH ELBOW EXTENSION
The second out-of-synergy motion is shoulder flexion to a
forward-horizontal position with the elbow extended.
If the patient is unable actively to flex the shoulder forward,
even with the therapist providing local facilitation and
guidance of movement, then the arm is brought passively
into position.
While tapping over the anterior and middle deltoid muscles,
the therapist asks the patient to hold the position.
If hold after positioning is accomplished, active motion in
small increments is then sought starting with lowering of the
arm followed by active shoulder flexion.
Stroking and rubbing of the triceps are used to assist in
keeping the elbow straight as the arm is raised.
ie continues until the full forward flexion motion can be
one.
TRAINING PRONATION AND
SUPINATION WITH ELBOW FLEXED
© The third motion sought in stage 4 is pronation
and supination with the elbow flexed to 90°.
© Physiotherapist should try to combine pronation
of the extensor synergy with elbow flexion of
the flexor synergy.
© Initially, pronation can be resisted with the
elbow extended, and gradually the elbow can
be brought into flexion as the resistance to
pronation is repeated. (perform task oriented
training to master the movement).
SUPINATION WITH ELBOW FLEXED
© The third motion sought in stage 4 is pronation
and supination with the elbow flexed to 90°.
© Physiotherapist should try to combine pronation
of the extensor synergy with elbow flexion of
the flexor synergy.
© Initially, pronation can be resisted with the
elbow extended, and gradually the elbow can
be brought into flexion as the resistance to
pronation is repeated. (perform task oriented
training to master the movement).
Pthomegroup
BRUNNSTROM TRAINING (STAGE-5)
© Movement in stage 5 involves active attempts
by the patient to move in patterns
increasingly away from synergy.
© Excess effort is avoided, however, so that the
limbs will not revert back to stereotyped
movements.
© The attempts are bolstered by use of quick
stretch and tactile stimulation. Each new
motion is incorporated into functional
activities.
BRUNNSTROM TRAINING (STAGE-5)
© Movement in stage 5 involves active attempts
by the patient to move in patterns
increasingly away from synergy.
© Excess effort is avoided, however, so that the
limbs will not revert back to stereotyped
movements.
© The attempts are bolstered by use of quick
stretch and tactile stimulation. Each new
motion is incorporated into functional
activities.
Pthomegroup
TRAINING SHOULDER ABDUCTION
WITH ELBOW EXTENSION
© The first motion sought in stage 5 is arm raised
to side-horizontal, which combines full shoulder
abduction with elbow extension.
© When this can be accomplished, disassociation
of components of the synergies has occurred.
© When the muscles are still under the influence of
the synergies, the arm will drift toward horizontal
adduction when the elbow is extended or the
elbow will flex when the shoulder is abducted.
© Practice with functional tasks assists learning.
TRAINING SHOULDER ABDUCTION
WITH ELBOW EXTENSION
© The first motion sought in stage 5 is arm raised
to side-horizontal, which combines full shoulder
abduction with elbow extension.
© When this can be accomplished, disassociation
of components of the synergies has occurred.
© When the muscles are still under the influence of
the synergies, the arm will drift toward horizontal
adduction when the elbow is extended or the
elbow will flex when the shoulder is abducted.
© Practice with functional tasks assists learning.
Pthomegroup
SCAPULAR MOBILISATION TO TRAIN
OVER HEAD ARM MOVEMENT
e The second motion of stage 5 is arm overhead.
e To achieve it, the scapula must upwardly rotate.
© The serratus anterior must be specifically
retrained to do this.
© If the scapula is bound by spastic retractors,
passive mobilization may need to be done before
seeking an active response.
© Passive mobilization of the scapula is done by
grasping the vertebral border and rotating it as the
arm is passively moved into an overhead position.
SCAPULAR MOBILISATION TO TRAIN
OVER HEAD ARM MOVEMENT
e The second motion of stage 5 is arm overhead.
e To achieve it, the scapula must upwardly rotate.
© The serratus anterior must be specifically
retrained to do this.
© If the scapula is bound by spastic retractors,
passive mobilization may need to be done before
seeking an active response.
© Passive mobilization of the scapula is done by
grasping the vertebral border and rotating it as the
arm is passively moved into an overhead position.
©
©
©
©
TRAINING SERRATUS ANTERIOR
Once the scapula is mobilized, the serratus is activated
in its alternate duty of scapula protraction by placing the
arm in the forward-horizontal position and asking, and
assisting, the patient to reach forward.
It is helpful to rehearse this motion with the patient using
the non-involved extremity.
Quick stretches are applied by pushing backward into
scapular retraction and the patient is asked to hold.
Once activated, a holding contraction of the serratus is
sought.
These procedures continue, moving the arm in
increments toward the arm overhead position.
Once the movement has been achieved, practice with
functional activities reinforces it.
©
©
©
TRAINING SERRATUS ANTERIOR
Once the scapula is mobilized, the serratus is activated
in its alternate duty of scapula protraction by placing the
arm in the forward-horizontal position and asking, and
assisting, the patient to reach forward.
It is helpful to rehearse this motion with the patient using
the non-involved extremity.
Quick stretches are applied by pushing backward into
scapular retraction and the patient is asked to hold.
Once activated, a holding contraction of the serratus is
sought.
These procedures continue, moving the arm in
increments toward the arm overhead position.
Once the movement has been achieved, practice with
functional activities reinforces it.
TRAINING SUPINATION AND PRONATION
WITH ELBOW EXTENDED
© The third motion sought in stage 5 is supination and
pronation (external and internal rotation) with the elbow
extended.
© The best way to achieve this control is by using both
hands in activities of interest to the patient that involve
supination and pronation in various arm positions.
© One activity that can be used is gr ping a large ball
with the arms outstretched and then rotating it so the
affected arm is On top (pronated) and the unaffected
arm is On the bottom (supinated) and vice versa.
© To improve supination, the elbow is at first kept close to
the trunk and gradually extended. Resistance is offered
to supination in elbow flexed position and gradually the
elbow is extended.
WITH ELBOW EXTENDED
© The third motion sought in stage 5 is supination and
pronation (external and internal rotation) with the elbow
extended.
© The best way to achieve this control is by using both
hands in activities of interest to the patient that involve
supination and pronation in various arm positions.
© One activity that can be used is gr ping a large ball
with the arms outstretched and then rotating it so the
affected arm is On top (pronated) and the unaffected
arm is On the bottom (supinated) and vice versa.
© To improve supination, the elbow is at first kept close to
the trunk and gradually extended. Resistance is offered
to supination in elbow flexed position and gradually the
elbow is extended.
Pthomegroup
PLEASE NOTE:
o Patients who recover comparatively rapidly after a
stroke may spontaneously achieve stage 6; however,
many hemiplegic patients do not achieve full recovery.
e Twitchell (1951) stated that patients who reached
stages 3 and 4 within 10 days after stroke recovered
completely; this has never been verified in the
literature.
© In Twitchell's sample, patients who failed to respond
to proprioceptive facilitation did not recover willed
movement at all.
© He observed, and it is generally accepted, that the
longer the duration of the flaccid stage, the less likely
was recovery.
PLEASE NOTE:
o Patients who recover comparatively rapidly after a
stroke may spontaneously achieve stage 6; however,
many hemiplegic patients do not achieve full recovery.
e Twitchell (1951) stated that patients who reached
stages 3 and 4 within 10 days after stroke recovered
completely; this has never been verified in the
literature.
© In Twitchell's sample, patients who failed to respond
to proprioceptive facilitation did not recover willed
movement at all.
© He observed, and it is generally accepted, that the
longer the duration of the flaccid stage, the less likely
was recovery.
RETRAINING WRIST AND HAND
FUNCTION
e It can be often seen that the hand may be ata
different stage of recovery than the arm.
© If the patient is unable to initiate active finger
flexion (hand stage 1) or mass grasp (hand
stage 2), the traction response in which
stretch of the scapular adductors produces
reflex finger flexion or an associated reaction
to resisted grasp by the non affected hand
may be used in combination with voluntary
effort.
FUNCTION
e It can be often seen that the hand may be ata
different stage of recovery than the arm.
© If the patient is unable to initiate active finger
flexion (hand stage 1) or mass grasp (hand
stage 2), the traction response in which
stretch of the scapular adductors produces
reflex finger flexion or an associated reaction
to resisted grasp by the non affected hand
may be used in combination with voluntary
effort.
thomegrot
DEVELOPING WRIST CONTROL
© In hemiplegia, wrist flexion usually accompanies
grasp initially so stability of the wrist in extension
must be developed.
o It is easier for the patient to stabilize the wrist in
extension when the elbow is extended; therefore,
training starts with the elbow extended and the
wrist supported by the therapist.
© The wrist extensor muscles are facilitated, and
the therapist directs the patient to do a forceful
grasp by commanding, “Squeeze. "
DEVELOPING WRIST CONTROL
© In hemiplegia, wrist flexion usually accompanies
grasp initially so stability of the wrist in extension
must be developed.
o It is easier for the patient to stabilize the wrist in
extension when the elbow is extended; therefore,
training starts with the elbow extended and the
wrist supported by the therapist.
© The wrist extensor muscles are facilitated, and
the therapist directs the patient to do a forceful
grasp by commanding, “Squeeze. "
DEVELOPING WRIST CONTROL
e The grasp promotes normal synergistic
contraction of the wrist extensors.
o This is repeated until the wrist extensors are felt
to respond, allowing the therapist to remove
support from the wrist with the command, "Hold."
© Tapping on the wrist extensor muscles facilitates
holding. Once wrist extension and grasp are
possible with the elbow extended, the process of
positioning, percussion, and hold is repeated in
increasing amounts of elbow flexion.
© Wrist flexion extension and circumduction can
then be practiced.
e The grasp promotes normal synergistic
contraction of the wrist extensors.
o This is repeated until the wrist extensors are felt
to respond, allowing the therapist to remove
support from the wrist with the command, "Hold."
© Tapping on the wrist extensor muscles facilitates
holding. Once wrist extension and grasp are
possible with the elbow extended, the process of
positioning, percussion, and hold is repeated in
increasing amounts of elbow flexion.
© Wrist flexion extension and circumduction can
then be practiced.
DEVELOPING FINGER EXTENSION
e To move from hand stage 3 (flexion) to hand stage
4 (semi voluntary mass extension) spasticity of the
finger flexors must be relaxed using a series of
manipulations.
© The therapist reflexively releases the patient's
grasp by holding the thumb into extension and
abduction.
e Still holding the thumb, the therapist slowly and
rhythmically supinates and pronates the forearm.
© Cutaneous stimulation is given over the dorsum of
the wrist and hand while the forearm is supinated.
e To move from hand stage 3 (flexion) to hand stage
4 (semi voluntary mass extension) spasticity of the
finger flexors must be relaxed using a series of
manipulations.
© The therapist reflexively releases the patient's
grasp by holding the thumb into extension and
abduction.
e Still holding the thumb, the therapist slowly and
rhythmically supinates and pronates the forearm.
© Cutaneous stimulation is given over the dorsum of
the wrist and hand while the forearm is supinated.
jroup
DEVELOPING FINGER EXTENSION
© These manipulations continue until a release of flexor
tension is seen by some relaxation of the flexed position.
If relaxation is incomplete, further manipulations are done.
With the forearm still supinated, rapid repeated stretch
stimuli are applied to the dorsum of the fingers by rolling
them toward the palm with a rapid stroking motion to
stretch finger extensors.
When flexor tension is relaxed, the forearm is pronated
and the arm elevated above horizontal (Souque's
phenomenon).
Stroking over the dorsum of the fingers and forearm
continues as extension is attempted, but effort exerted
should be minimal to avoid a build-up of tension.
DEVELOPING FINGER EXTENSION
© These manipulations continue until a release of flexor
tension is seen by some relaxation of the flexed position.
If relaxation is incomplete, further manipulations are done.
With the forearm still supinated, rapid repeated stretch
stimuli are applied to the dorsum of the fingers by rolling
them toward the palm with a rapid stroking motion to
stretch finger extensors.
When flexor tension is relaxed, the forearm is pronated
and the arm elevated above horizontal (Souque's
phenomenon).
Stroking over the dorsum of the fingers and forearm
continues as extension is attempted, but effort exerted
should be minimal to avoid a build-up of tension.
thomegrot
IMITATION SYNKINESIS
© Imitation synkinesis, in which the normal side
performs a motion that is difficult to achieve on
the involved side, may be observed when the
patient attempts finger extension.
o After the fingers can be voluntarily extended
with the arm raised, the arm is gradually
lowered.
© If there is an increase of flexor tension
reflected by decreased range in extension, it is
necessary to repeat the above manipulations
to inhibit flexion and facilitate extension.
IMITATION SYNKINESIS
© Imitation synkinesis, in which the normal side
performs a motion that is difficult to achieve on
the involved side, may be observed when the
patient attempts finger extension.
o After the fingers can be voluntarily extended
with the arm raised, the arm is gradually
lowered.
© If there is an increase of flexor tension
reflected by decreased range in extension, it is
necessary to repeat the above manipulations
to inhibit flexion and facilitate extension.
TASK ORIENTED TRAINING
© Reaching and picking up large, lightweight
objects and releasing them is required to
practice finger extension.
© The larger the object, the greater the
extension required.
e The other extensor type activities are those
that require the hand to be used fiat, such as
smoothing out a garment while ironing or a
sheet while making the bed.
© Reaching and picking up large, lightweight
objects and releasing them is required to
practice finger extension.
© The larger the object, the greater the
extension required.
e The other extensor type activities are those
that require the hand to be used fiat, such as
smoothing out a garment while ironing or a
sheet while making the bed.
Pthomegroup
DEVELOPING LATERAL
PREHENSION AND RELEASE
e The second motion sought at hand stage 4 is lateral
prehension and release.
© The patient attempts to move the thumb away from
the index finger to gain release of lateral prehension
while the therapist percusses or strokes over the
abductor pollicis longus tendon to facilitate this
motion.
© Once the patient has some active release, functional
use of lateral prehension is then encouraged.
o Activities include holding a book while reading,
dealing cards, and using a key.
DEVELOPING LATERAL
PREHENSION AND RELEASE
e The second motion sought at hand stage 4 is lateral
prehension and release.
© The patient attempts to move the thumb away from
the index finger to gain release of lateral prehension
while the therapist percusses or strokes over the
abductor pollicis longus tendon to facilitate this
motion.
© Once the patient has some active release, functional
use of lateral prehension is then encouraged.
o Activities include holding a book while reading,
dealing cards, and using a key.
PROGRESSING TO STAGE-5
© Once the patient is able voluntarily to extend the fingers
to release objects, advanced prehensile patterns (hand
stage 5) are encouraged through activities.
© Musical instruments (drum, claves, tomtom, etc.)
provide motivating opportunities for gross use of various
hand patterns (Cofrancesco, 1985).
o As the patient progresses, activities are chosen to
reinforce particular prehensions at more precise levels.
© Holding a pencil or paintbrush encourages palmar
prehension.
© Spherical grasp is used to pick up or hold round objects
such as a jar lid or an orange, and cylindrical grasp is
used when holding the handles of tools.
© Once the patient is able voluntarily to extend the fingers
to release objects, advanced prehensile patterns (hand
stage 5) are encouraged through activities.
© Musical instruments (drum, claves, tomtom, etc.)
provide motivating opportunities for gross use of various
hand patterns (Cofrancesco, 1985).
o As the patient progresses, activities are chosen to
reinforce particular prehensions at more precise levels.
© Holding a pencil or paintbrush encourages palmar
prehension.
© Spherical grasp is used to pick up or hold round objects
such as a jar lid or an orange, and cylindrical grasp is
used when holding the handles of tools.
STAGE-6 REHABILITATION
© Individual finger movements (hand stage 6)
may be regained in rare instances.
© The patient should be given a home program
of activities to encourage more and more
individual finger use and to increase speed
and accuracy of hand movements, but he
should also be cautioned about expecting
100% recovery.
© Individual finger movements (hand stage 6)
may be regained in rare instances.
© The patient should be given a home program
of activities to encourage more and more
individual finger use and to increase speed
and accuracy of hand movements, but he
should also be cautioned about expecting
100% recovery.
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