Approaches+to+Therapeutic+Exercise+and+Activity+for+Neurological

Approaches to Therapeutic

Exercise and Activity for

Neurological and Developmental

Conditions (Bobath and Brunnstrom Approaches)

PT 154: Therapeutic Exercise III

Ms. Mary Grace M. Jordan, PTRP

23 November 2009

Learning Objectives

At the end of the lecture, the students should be

able to:

Discuss the theoretical basis of the

neurodevelopmental approaches

Discuss the concepts and principles underlying

the Bobath approach

Discuss the concepts and principles underlying

the Brunnstrom approach

Sensorimotor Approaches

Bobath approach

Brunnstroms movement therapy

Rood approach

Proprioceptive neuromuscular facilitation

Theoretical basis

Neurodevelopmental model

Reflex theory

Hierarchical theory

Systems approach

Neurodevelopmental Model

motor control and its production refers to

two systems of output: the open loop

(voluntary control ) and the closed loop

(postural control) mechanisms

(Keshner, , 1981)

Open-loop system

commands sequences of movement that

are centrally stored in the nervous system

and that serve the functions of mobility in

the production of isolated joint and limb

motions

(Keshner, , 1981)

Closed-loop system

Dependent upon afferent feedback for

the elicitation of its automatic movements

that serve as the principle motility or

stability of the organism

prerequisite for the development of

normal movement behaviors

arise from patterns of coordination

Reflex Theory

The basic unit of motor control are reflexes

Reflexes purposeful movement

Damage to the CNS results to re-emergence of

and inability to control the reflexes

Hierarchical Theory

Motor control is hierarchically arranged

CNS structures involved with movement can be

grouped into HIGHER, MIDDLE, and LOWER

levels

Higher centers regulate and control the middle

and lower centers

Damage to the CNS results to disruption of the

normal coordinated function of these levels

Systems approach

suggests that the CNS does not operate in a

strictly descending manner

no higher levels with which to control the

operation of the lower levels

there is a mutable relationship between the

various levels so that each level will alternate

between command and subordinate roles in

relation to the other levels.

(Keshner, , 1981)

Bobath Approach

Concepts and Principles

History

Developed by Dr. Karel Bobath, a

neuropsychiatrist, and Mrs. Berta Bobath, a

physical therapist

1943 while working with children with

cerebral palsy

Original theoretical framework

Based on the works of Jackson,

Sherrington, and Magnus

who described nervous system as HIERARCHICAL in nature

Model

Higher brain centers exerted control over lower-level centers

Eg. The cerebral cortex control supercedes that of the brainstem

Original theoretical framework

Hypothesis

A neurologic insult will lead to a release of

the lower-level centers from higher-level

center inhibitory control, resulting in

stereotypical postures, primitive movement

patterns and predominant reflex activity

Adult hemiplegia..

Treatment approach was later on expanded

to include the rehabilitation of adults with

motor problems, particularly CVA

Main problem: the abnormal coordination

of movement patterns combined with

abnormal postural tonus (Bernstein, 1967)

Secondary problem: muscle strength and

muscle activity

Bobath concept

Is a living concept, it is not static

It has undergone changes in its theoretical base to accommodate developments in the

fields of neurophysiology, biomechanics, and

typical development

Holistic approach

It involves the whole patient, his sensory, perceptual and adaptive behaviour, and motor

problems

Traditional View

Principles of treatment Normalize muscle tone

Inhibit primitive reflexes

Facilitate normal postural reactions

Treatment should be developmental

Techniques Handling

Weight bearing over the affected limb

Utilize positions that allow use of the affected limbs

Avoidance of sensory input that affect muscle tone

Previously

The control of movement was thought to be

dependent on the normal postural reflex

mechanism

E.g. utilizing righting reactions and equilibrium reactions in association with

normal postural tone

Reconstruction of

the

NDT approach

Hierarchical Theory

Systems Theory

Premise

Different parts of the CNS influence one

another

Nervous system is capable of initiating,

anticipating, and controlling movements

feedforward and feedback mechanisms

CNS has the ability to shape and/or renew

itself in response to practiced activities:

neuroplasticity

Evidence on neuroplasticity

(Fisher, BE and Sullivan, KJ, 2001)

Neuroplasticity can occur on the lesioned side of the cerebral cortex following CVA when provided appropriate practice in using involved side

Rehabilitation strategies should promote recovery rather than compensation

Techniques should incorporate the following:

Active participation in motor skill learning

Specific skills training and strengthening directed to the involved limbs

Intense, task-specific practice that optimizes the sensorimotor experience

Basic premises

Sensations of movements are learned, not

movements per se

Basic postural and movement patterns are

learned that are later elaborated on to

become functional skills

Problems in the adult patient with

stroke

Abnormal tone

Loss of postural control

Abnormal coordination

Abnormal functional performance

Goals

Decrease the influence of spasticity and

abnormal coordination

Improve control of the involved trunk, arm

and leg

Retain normal, functional patterns of

movement in the adult stroke patient

Principles of treatment:

Adult hemiplegia

Treatment should avoid movements and

activities that increase muscle tone or produce

abnormal reflex patterns in the involved side

Treatment should be directed toward the

development of normal patterns of posture and

movement (movement patterns are not based on

the developmental sequence but on patterns

important for function)


Adult hemiplegia

The hemiplegic side should be incorporated

into all treatment activities to reestablish

symmetry and increased functional use

Treatment should produce a change in the

quality of movement and functional

performance of the involved side


Adult hemiplegia

Individualize functional outcomes

Emphasize motor control

Increase active use of the involved side

Provide practice to improve motor performance that lead to motor learning

Teach 24-hour management to increase retention and carryover

Use an interdisciplinary approach to intervention

Stages of hemiplegia and the

Bobath Approach

Initial Flaccid Stage

tx focus on positioning and movement in bed to avoid the typical postural patterns of

hemiplegia

Stage of Spasticity

tx is a continuation of the previous stage with the goal of breaking down the total patterns by

developing control of the intermediate joints

Stages of hemiplegia and the

Bobath Approach

Stage of Relative Recovery

tx aims at improving the quality of gait and the use of the affected hand

Principles of treatment: children

with cerebral palsy

Treat the child as a whole

Basis for intervention is normal movement and their interrelationships

Treatment incorporates facilitation and inhibition using key points of control

abnormal tone is always inhibited

normal responses, once elicited, are always repeated

What are key points of control

(KPC)? Parts of the body where the therapist can most

effectively control and change patterns of posture and movement in other body parts

Proximal: spine, sternum, shoulder/scapula, pelvis/hip

Distal: jaw, elbow, wrist, knee, base of the thumb, ankle, big toe

Head may be a proximal or distal KPC

use KPC that allow full pattern to be broken during handling

Facilitation-Inhibition

Facilitation

is a mean by which movement is made easy, made possible, and made necessary

Inhibition

involves decreasing the use of pathological movements and the effects of tonal dysfunctions

on movement

Facilitation and inhibition may be used

simultaneouly and may be applied throughout

the session

What is handling? Manner of controlling the patient through

tone influencing patterns

Normal patterns of activity used to modify abnormal patterns of posture and movement

o Total TIPs: whole body is controlled in a reversal of the abnormal pattern

o Partial TIPs: some body parts remain free to move

TIPs are utilized via KPCs

Law of Shunting

at any moment during the movement or a

postural change, the CNS mirrors or reflects

faithfully, the state of the body

musculature

Therefore, it is the body musculature which

guides and directs the CNS

Thus, tone inhibiting patterns are used to

give the CNS the sensation of normal

movements

Child must be active during treatment to achieve functional goals

Voluntary control of normal responses is encouraged

Treatment and evaluation are ongoing

Treatment if functionally-oriented


with cerebral palsy

NDT is appropriate for persons with

sensorimotor dysfunction regardless of

age and cognition

Non-professionals can be an active

participant in treatment


with cerebral palsy

Treatment methods

Modify sensory input through handling,

positioning reflex inhibiting postures and

use of key points of control

Facilitate automatic reactions

Normal movement patterns are integrated

into developing nervous system

OLD THEORY NEW THEORY

Hierarchical brain organization (Reflex

model)

Systems Model

Normal postural reflex mechanism as the

basis of normal movement

Postural control is learned together with

the skill; feedback and feedforward

mechanisms needed for efficient

movement control

Static postures and positions used for

treatment

Client is an active participant in the

session

Progressing the client through normal

developmental milestones

Developmental milestones serve as

guidelines but should not be strictly

adhered to

Development of control proceeds in a

cephalocaudal direction

Control of movement develops in

proximal to distal or distal to proximal

directions

Work on components of motions which

the child will then apply to function

Client must work on functional tasks to

learn the skill

Evidence

The Effectiveness of the Bobath

Concept in Stroke Rehabilitation

Boudewijn, K. et al. (2009)

Stroke. 2009;40:e89.

16 studies involving 813 patients with stroke were

included for further analysis.

There was no evidence of superiority of Bobath on

sensorimotor control of upper and lower limb, dexterity,

mobility, activities of daily living, health-related quality

of life, and cost-effectiveness.

Only limited evidence was found for balance control in

favor of Bobath.

Brunnstroms Movement

Therapy

Concepts and Principles

History

Developed by Signe Brunnstrom, a physical

therapist from Sweden

Theoretical foundations: Sherrington

Magnus

Jackson

Twitchell

Premise

When the CNS is injured, as in CVA, an

individual goes through an evolution in

reverse

Movement becomes primitive,

reflexive, and automatic

Changes in tone and the presence of

reflexes are considered part of the normal

process of recovery

Principles of treatment

Facilitate the patients 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

Resistance facilitates contraction

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

Important! (Limb 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 synergies: UE

Scapula: retraction and/or elevation

Shoulder: abduction and ext rotation

Elbow: flexion

Forearm: supination

Flexor

Synergy

Scapula: protraction and /or depression

Shoulder: adduction and int rotation

Elbow: extension

Forearm: pronation

Extensor

Synergy

Basic limb synergies: UE

Hip: flexion, abduction, and ext rotation

Knee: flexion

Ankle: dorsiflexion

Toe: extension

Flexor

Synergy

Hip: extension, adduction, and int rotation

Knee: extension

Ankle: plantarflexion

Toe: flexion

Extensor

Synergy

Extensor

Flexor

Mixed synergy: UE

Strongest elbow flexion shoulder adduction internal rotation

Next

strongest forearm pronation

Weakest shoulder abduction elbow flexion

external rotation

Mixed synergy: LE

Flexor

Extensor

Strongest hip flexion hip adduction knee extension

ankle plantarflexion ankle inversion

Weakest hip abduction hip extension

external rotation hip int rotation

toe flexion

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

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 flexion

Skull side:

upper extremity flexion

lower extremity extension

Tonic Labyrinthine Reflexes

Tonic Lumbar Reflex

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

Associated reactions Investigation by Walshe (1923)

Associated reactions are released postural reactions deprived of voluntary control

Investigation by Simons (1923) Position of the head has a marked influence on

the outcome of the associated rections

Limb reactions evoked closely resemble tonic neck reflexes

Observations by Brunnstrom (1951,1952) UE: movements employed elicited the same

reactions in the affected limb

LE: movements employed elicited opposite reactions in the affected limb

Associated reactions

Observations by Brunnstrom

(1951, 1952)

may be evoked in a limb that is essentially flaccid, although latent spasticity may be present

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

tension in the muscles of the affected limb

decrease rapidly after cessation of stimulus that

evoked the associate directions

attitudinal reflexes influence the outcome of

associated reactions


Homolateral Limb Synkinesis

The response of one extremity to stimulus

will elicit the same response in its ipsilateral

extremity

Raimistes Phenomenon

Resisted abduction or adduction of the

sound limb evokes a similar response in the

affected limb


Yawning

Flexor synergy is elicited during initiation of

yawn

Coughing and Sneezing

Evoke sudden muscular contractions of short

duration

Hand reactions

Steps to restoration of hand function (Twitchell, 1951)

1. Tendon reflexes return and become hyperactive

2. Spasticity develops; resistance to passive motion is felt

3. Voluntary finger flexion occurs, if facilitated by proprioceptive stimuli

Hand reactions

4. Proprioceptive traction response can be

elicited

Aka proximal traction response

Stretch of flexors of one of the joints of the

upper limb facilitates a contraction of the flexor

muscles of other joints of the same limb thus

producing total limb shortening

5. Control of hand without proprioceptive

stimuli begins

Hand reactions

6. Grasp is reinforced by tactile stimulus on

the palm of the hand; spasticity declines

7. True grasp reflex can be elicited; spasticity

further declines

Elicited by disctally moving deep pressure over

certain areas of the palm and digits

Catching phase: weak contraction of flexors and

adductors upon stimulus

Holding phase: proceeds when traction is done on

muscles activated in the catching phase

Other 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

Soques Finger Phenomenon Elevation of the hemiplegic arm beyond the

horizontal results to estension and abduction of the fingers

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

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 normalcy Spasticity disappears: individual is more capable of full movement patterns

Stage

7 Normal motor functions are restored

Treatment Principles

1. 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


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

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.


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 3.

7. Correct movement once elicited is repeated

Reference

Bandong, A. (2008). Approaches to therapeutic exercise:

Concepts, principles, and strategies. Power point lecture

presentation in PT 154.

Bobath B (1990). Adult hemiplegia: Evaluation and treatment

(3rd ed). Oxford, Heinemann Medical Books.

Levitt S (2004). Treatment of cerebral palsy and motor delay

(4th ed). Singapore, McGraw-Hill Inc.

Sawner K & LaVigne J (1992). Brunnstroms Movement

Therapy in hemiplegia: A Neurophysiological Approach

(2nd ed). Philadelphia, J.B. Lippincott Company.

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Approaches+to+Therapeutic+Exercise+and+Activity+for+Neurological