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)
Principles of treatment:
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
Principles of treatment:
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
Principles of treatment: children
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
Principles of treatment: children
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
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
Associated reactions
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
Treatment Principles
3. Resistance (proprioceptive stimulus)
promotes a spread of impulses to produce a
patterned response while tactile stimulation
facilitates only the muscle related to the
stimulated area
Treatment Principles
4. When voluntary effort produces or
contribute to a response, patient is asked to
hold the contraction (isometric). If
successful, an eccentric (contracted
lengthening) is performed and finally a
concentric (shortening) contraction is done.
Treatment Principles
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.