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Brunnstrom Approach

Brunnstrom's Approach (SIGNE BRUNNSTROM) Objectives: ➢ Discuss the concepts and principles underlying Brunnstrom’s approach ➢ Brunnstrom recovery stages ➢ Treatment principles & techniques

★ Brunnstrom’s approach was developed by the physical therapist from Sweden in the early 1950s ★ Brunnstrom used motor control theory and observations of the patients' ★ Procedure: In a “trial & error” fashion ★ Later modified: in light of neurophysiological knowledge

Introduction: Reflex Theory Movement is controlled by stimulus-response. Reflexes are the basis for movement: reflexes are combined into actions that create behavior. Hierarchical Theory Characterized by a top-down structure, in which higher centers are always in charge of lower centers. ● When the CNS is injured, as, in a cerebrovascular accident, an individual goes through an “evolution in reverse”. Movement becomes primitive, reflexive, and automatic. ● Changes in tone and the presence of reflexes are considered a normal process of recovery. ● Movement recovery tends to be stereotypic. ● Patients exhibit only a few stereotypic movement patterns: Basic Limb Synergies. ● Based on observations of recovery following a stroke, this approach makes use of associated reactions, tonic reflexes, and the development of basic limb synergies to facilitate movements. ● The use of such a procedure is temporary.

Basic Limb Synergies: ● Normal synergistic movements are purposeful movements with maximum precision and minimum waste of energy. ● Basic limb synergy (BLS) does not permit the different combinations of muscles. ● BLS is considered primitive, automatic, and reflexive due to loss of inhibitory control from higher centers. ● Mass movement patterns in response to a stimulus or voluntary effort both Gross flexor movement (Flexor Synergy) Gross extensor movement (Extensor Synergy) Combination of the strongest component of the synergies (Mixed Synergy) ● Appear during the early spastic period of recovery

Upper Limb Flexor Synergy: Scapula: Retraction / Elevation Shoulder: Abduction and External rotation Elbow: Flexion Forearm: Supination Wrist and Finger: Flexion Lower Limb Extensor Synergy: Pelvis: posterior tilt Hip: Extension, Adduction & Internal rotation Knee: Extension Ankle: Plantarflexion Toes: Flexion Upper Limb Extensor Synergy: Scapula: Protraction / Depression Shoulder: Adduction and Internal rotation Elbow: Extension Forearm: Pronation Wrist: Extension Finger: Flexion Lower Limb Flexor Synergy: Pelvis: anterior tilt Hip: Flexion, Abduction & External rotation Knee: Flexion Ankle: Dorsiflexion Toes: Extension

Upper Limb Mixed Synergy: Scapula retraction Shoulder add.+IR Elbow flexion Forearm pronation Wrist & fingers flexion Lower Limb Mixed Synergy: Pelvis post tilt hip add.+IR Knee extension Ankle & toes plantarflexion (Rubrospinal tract Vestibulospinal tract)

Associated Reactions: Voluntary forceful movement in other parts of the body readily elicits reflex tensing of muscles and involuntary movements of affected limbs known as Associated reactions. ● An investigation by Simon (1923) Position of the head has a marked influence on the outcome of the associated reactions Limb reactions evoked closely resemble tonic neck reflexes ● Observations by Brunnstrom (1951 & 1952) UE: movements employed elicited same reactions in the affected limb LE: movements employed elicited opposite reactions in the affected limb ● Homolateral Limb Synkinesis: the response of one extremity to a stimulus will elicit the same reaction in its ipsilateral extremity. ● Raimiste’s Phenomenon: resisted abduction or adduction of the sound limb evokes a similar reaction in the affected limb. ● Associated reactions are also evoked by Yawning, Sneezing, and Coughing. Postural Reactions: ● Asymmetric Tonic Neck Reflex (ATNR): Head rotation to the left causes extension of the left arm and leg and flexion of right arm and leg; head rotation to the right causes extension of right arm and leg and flexion of left arm and leg. ● Symmetric Tonic Neck Reflex (STNR): Flexion of the neck results in flexion of the arms and extension of the legs; extension of the neck results in extension of the arms and flexion of the legs. ● Tonic Labyrinthine Reflex (TLR): Prone lying position facilitates flexion; the supine position facilitates extension. The reflex can also be thought of as inhibition of extensor tone in the prone position

Brunnstrom Recovery Stages: ● Brunnstrom's stereotyped sequence of events takes place during recovery. ● Initially classified into six stages later on modified into seven recovery stages. ● Depending on the severity of the insult and the degree of the sensory-motor involvement, recovery may get arrested at any stage in the process. ● Stages cannot be skipped. ● In some cases, especially when the insult is minor, the recovery may proceed rapidly with no distinct observable stages. ● Believes that the stages of recovery resemble normal infantile motor development.

As recovery begins, BLS or some of their components appears as associated reactions, or minimal voluntary responses may be present. Spasticity begins to develop and may be particularly evident in muscle groups that dominate synergy movement (e.g. elbow flexors and knee extensors). Seen soon after the acute episode, affected limbs are essentially flaccid, no voluntary or reflexive movements possible. Recovery Stages of Brunnstrom: The patient gains voluntary control on BLS, full range of all synergy components is not mandatory, spasticity reaches its peak: consider as the semi-voluntary stage. Some movement combinations that do not follow the paths of BLS are mastered, first with difficulty and then with ease; spasticity begins to decline; the influence of spasticity on non-synergistic movements is readily observable. As recovery continues, more difficult movement combinations away from the path of BLS are mastered; the dominance of BLS over motor control reduces; spasticity continues to decline. Individual joint movements possible; coordination reaching normally, absence of spasticity. Normal motor functions restored. Tendon Reflex Spasticity Voluntary finger flexion on proprioceptive stimulus Proprioceptive traction response Control of hand movements Grasp reinforcement True grasp reflex Brunnstrom Recovery Stages for Lower limb: Flaccidity Minimal voluntary movements of the lower limb Hip - Knee - Ankle flexion in sitting and standing Sitting knee flexion beyond 90 degrees with foot sliding backward on the floor, voluntary ankle dorsiflexion without lifting the foot from the ground Standing isolated knee flexion beyond with hip extension, isolated ankle dorsiflexion with knee extension, heel forward in a position of short step Standing hip abduction with pelvis elevation, knee inner and outer rotation, combined with ankle inversion and eversion. Treatment Principles: 1. Treatment progress developmentally, so facilitate the patient’s progress throughout the recovery stages. 2. When no motion exists, movement is facilitated using reflexes, associated reactions, proprioceptive facilitation/exteroceptive facilitation to develop muscle tension in preparation for voluntary movement. 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. When voluntary effort produces or contributes to a response, the patient is asked to hold the isometric contraction. If successful eccentric is performed and finally a concentric contraction is done. 5. Facilitation is reduced or dropped out as quickly as the patient shows evidence of volitional control. 6. No primitive reflexes, including associated reactions, are used beyond stage 7. Correct movement once elicited is repeated.

Bad Posture and Bed Exercises ● During flaccid conditions, the positioning of the limbs on the bed is the most favorable way without the interference of spastic muscles. ● In supine position: lower limb tends to produce extensor posture with hip abduction and external rotation: slight hip and knee flexion are recommended with a small pillow under the knee and lateral support to the knee to protect hip abduction and external rotation. ● The affected upper limb is supported on a pillow in a position that is comfortable for the patient.

● To avoid inferior subluxation of the glenohumeral joint, advice has to be given not to keep the shoulder in the abduction about the scapula. ● Avoid traction on the side of the affected arm and should be instructed to support his arm with his normal hand. ● During flaccidity, passive motions of the limbs are first carried out and then developed into active-assisted motions.

Brunnstrom exercise in the flaccid stage of hemiplegia: ● It includes 3 strategies: POSTURAL REFLEX LOCAL REFLEX ASSOCIATED REACTIONS 3 STRATEGIES

Treatment of Shoulder Pain: ● Adequate handling ● Prevent any shoulder motion above 90 degrees ● Maintain scapulohumeral rhythm ● Avoid vigorous passive fast movements ● Utilize scaption plane during exercise ● Use indirect method of mobilization in times of patient does not allow a exercise during severe shoulder pain

Treatment of Trunk Control Bilateral Rowing Exercise Hand Manipulation Exercise: Breaking Synergy Treatment of Lower limb in sitting Treatment of Lower Limb Standing Hemiplegic Gait Training

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