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CVA > Brunnstrom and NDT > Flashcards

Brunnstrom and NDT Flashcards

1
Q

Brunnstrom’s Approach to Exam and
Intervention

• Areas of examination:

A
  • Sensory function (passive motion sense of UE/LE, finger recognition, sole sensation, light touch, and temperature)
  • PROM
  • Postural reflexes
  • Recovery stages
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2
Q

Brunnstrom’s Approach to Exam and
Intervention

• Principles of Intervention:

A

• Creating movement by stimulating abnormal reflexes would carry-over into
normal patterns of movement

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3
Q

Post CVA

Which movement happens first in UE

A

Flexion

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4
Q

Brunnstrom’s Stages of Recovery***

A

• Stage 1: Flaccidity, no movement
• Stage 2: Minimal voluntary movement, associated reactions; spasticity begins
to develop
• Stage 3: Voluntary control of movement synergies; spasticity peaks in
severity
• Stage 4: Mastery of some movement combo outside of the synergies;
spasticity begins to decline
• Stage 5: Difficult movement combo are learned; synergies lose their
dominance
• Stage 6: Spasticity disappears, isolated joint movement & coordination
achieved
• Stage 7: Normal movement

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5
Q

Stages of Recovery:

Can stages be revisited or skipped?

A

NO

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6
Q

Stages of Recovery:

Patients progression

A

• Patients may plateau at any
stage

• Hemiplegic UE and LE may be in
different stages

• No set amount of time for each
stage

• Faster progress thru stages, more
functional

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7
Q 
Stage 1:
When does it happen?
How is movement like?
Motor tests:
For shoulder and elbow?
For hand?
For lower limb and trunk?
A

immediately following the acute episode, flaccidity of the
affected limbs is present, and no movement (either reflexive or
voluntary) can be initiated
- Shoulder and elbow: flaccidity during AROM/PROM and spasticity
testing
- Hand: flaccidity during AROM/PROM and spasticity testing
- Lower limb and trunk: flaccidity during AROM/PROM and spasticity
testing

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8
Q

Stage 2:

How is movement like?
Motor tests:
For shoulder and elbow?
For hand?
For lower limb and trunk?
A

minimal voluntary movements and/or associated reactions may appear. The basic limb synergies appear; flexor synergy in the UE and extensor synergy in the LE occur first. Spasticity begins to develop
- Shoulder and elbow: Observe flexor synergy. Test spasticity with
MAS (score 1 or 1+)
- Hand: little or no active finger flexion
- LE and trunk: minimal voluntary movements of the LE. Observe
extensor synergy in supine position. Test spasticity with MAS (score
1 or 1+).

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9
Q

Synergy - Abnormal synergies

A
  • Movement is bound together
  • Stereotyped
  • Primitive/Reflexive/Automatic
  • Limited combinations of movement
  • Muscles are bound together in UNITS of motion
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10
Q

UE Flexor Synergy Pattern***

A 
- Flexion of the elbow to an acute
angle
- Full range supination of the forearm
(sometimes pronation occurs)
- Abduction of the shoulder to 90
degrees
- External rotation of the shoulder
- Retraction and/or elevation of the
shoulder girdle
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11
Q

LE Extensor Synergy Pattern***

A 
- Plantar flexion of the toes
(inconsistent, big toe may be
extended)
- Plantar flexion and inversion of the
ankle
- Extension of the knee
- Extension of the hip
- Adduction and internal rotation of
the hip
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12
Q

Synergies

• Antagonist muscles to dominant components are:

A
  • Weaker
  • More difficult to elicit

• i.e. Biceps (elbow flexion) is dominant thus Triceps (elbow
extension and antagonist ) are weak.

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13
Q

UE Extension Synergy

A 
Shoulder girdle Depression and protraction
Shoulder Adduction and internal rotation
Elbow Extension
Forearm Pronation
Wrist Extension
Fingers Flexion
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14
Q

LE Extension Synergy

A

Hip

  • Extension
  • Adduction
  • Internal Rotation

Knee Extension

Foot/Ankle Plantarflexion Inversion

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15
Q

LE Flexion Synergy

A

Hip

Flexion
Abduction External
rotation

Knee Flexion (to 90 deg)

Foot/Ankle Dorsiflexion Inversion

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16
Q 
Stage 3: What happen to the synergies and spasticity***
Motor tests:
- Shoulder and elbow: 
- Hand: 
- LE and trunk:
A

Stage 3: Synergies become dominant, spasticity reaches its peak***
- Shoulder and elbow: Observe basic limb synergies, grade synergy based on
the active range of motion of each joint involved (25% is 1 point, 50% is 2
points, 75% is 3 points, 4 is full AROM at the joint)
- Hand: mass grasp; no voluntary finger extension; possibly reflexive
extension of fingers
- Mass grasp: proximal traction response. Maintain wrist in extension;
therapist supports arm and elbow. Command pt to squeeze

  • LE and trunk: synergies dominant; some non-stereotypical voluntary
    movements occur
  • Observe hip-knee-ankle flexion in sitting and standing
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17
Q 
Stage 4: What happen to the synergies and spasticity***
Motor tests:
- Shoulder and elbow: 
- Hand: 
- LE and trunk:
A

In addition to synergies some additional voluntary movements
appear. Spasticity declines
- Shoulder and elbow: spasticity declines, some non-stereotypical
voluntary movements occur (placing the hand behind the body,

elevation of the arm to forward-horizontal position, pronation-
supination with elbow at 90 degrees)

  • Hand: lateral prehension; semi-voluntary finger extension
  • LE and Trunk: gain more control over individual joints. Sitting, knee
    flexion beyond 90 degrees with the foot sliding backward on the
    floor. Voluntary DF of the ankle w/o lifting the foot off the floor
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18
Q 
Stage 5: What happen to the synergies and spasticity***
Motor tests:
- Shoulder and elbow: 
- Hand: 
- LE and trunk:
A

More complicated voluntary movements appear, synergies no longer
dominate, spasticity continues to decline

  • Shoulder and elbow: relative independent from synergies.
  • Arm raising to a side-horizontal
  • Arm raising forward and overhead
  • pronation-supination with elbow extended
  • Hand: palmar prehension; possibly cylindrical and spherical grasps;
    voluntary mass extension of fingers, variable range
  • LE and Trunk: Standing, isolated non-weight bearing knee flexion, hip
    extended or nearly extended; standing, isolated ankle DF with knee
    extended and heel forward in position of short step
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19
Q 
Stage 6: What happen to the spasticity***
Motor tests:
- Shoulder and elbow: 
- Hand: 
- LE and trunk:
A

Individual joint movements become possible, coordination
approaches normal, spasticity disappears except when the pt is under
stress or sick
- Shoulder and Elbow: isolated joint movements are freely performed
- Hand: All prehension types under control; full range voluntary
extension of fingers; individual finger movements present, less
accurate than on opposite side
- LE and Trunk: Standing, hip abduction beyond range obtained from
elevation of the pelvis.

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20
Q

Stage 6 additional tests:

Speed tests, UE:

A 
- The hand is moved from lap to
chin, requiring complete range
of flexion of the elbow
- the hand is moved from lap to
opposite knee, requiring full
range of extension of the elbow
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21
Q

Stage 6 additional tests:

Speed tests, hand:

A 
- Wrist flexion/extension, fist
closed
- Wrist circumduction
- Individual thumb movements
- Individual finger movements
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22
Q

Associated Reactions***:

What are they?

A

VOLUNTARY forceful movements in other parts of the body elicit similar
movements in the affected limbs
• Abnormal synergy
• The reflex contraction of muscle, that may include involuntary
limb movement

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23
Q

Associated Reactions***:
When they can present?
How to evoke a response?

A
  • May be present years after initial onset of hemiplegia

* Repeated stimulation may be required to evoke a response

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24
Q

Associated Reactions***:

What it does and does not show?

A
  • Does NOT show you the patient’s ability to voluntarily move
  • Does show you there is a way to initiate movement.
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25
Q

Associated Reactions***:

What does Brunnstrom say about it

A

• We can use the tone/movement created by these abnormal reflexes
to facilitate movements in an otherwise flaccid extremity

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26
Q

Associated Reactions***:
Found mostly in patients with…
When are they most pronounced?

A

Commonly elicited when spasticity is present
• However occasionally found in pts with little to no spasticity

• More pronounced when moving against resistance

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27
Q

UE Associated Reactions

A

Flexion = Flexion

Extension = Extension

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28
Q

LE Associated Reactions

A

Flexion = Extension

Extension = Flexion

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29
Q

Homolateral limb Synkinesis
What is it?
How does the UE/LE move?
Occurs in patients with?

A

• Movement of affected UE/LE elicits movement of other extremity of
affected side in the same direction at the same time

  • Both UE/LE move into flexion or extension direction
  • Occurs in patients with spastic hemiplegia
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30
Q

Associated Reactions - TREATMENT

• Raimiste’s Phenomenon

A

Abd or add of the unaffected LE (just hip) results in the same motion of the affected LE

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31
Q

Associated Reactions - TREATMENT

• Raimiste’-like Phenomenon

A

Abd or add of the unaffected UE results in the same motion of the affected UE

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32
Q

Associated Reactions - TREATMENT

• Souques’ Phenomenon

A

Reflex finger extension when the affected arm is passively flexed past 90° of shoulder
flexion

33
Q

Associated Reactions

• Rowing Patterns: what is it and what to do with the patient

A

• Another form of an associated
reaction

• Capitalize on bilateral
symmetrical activity

• Ask patient to pull back with
non-involved arm
• Hope to see involved arm move
as well
• Use of thumb grip or “shake
hands” with patient
34
Q

Postural Reflexes
• Present during

  • Become integrated during
  • Can reappear after
A
  • Present during normal development
  • Become integrated during infancy/youth
  • Can reappear after damage to brain
35
Q

Abnormal Postural Reflexes

A

Think as SAATT like a posture “sat”

  • Symmetrical Tonic Neck Reflex (STNR)
  • Asymmetrical Tonic Neck Reflex (ATNR)
  • Tonic Labyrinthine Reflex (TLR)
  • Asymmetrical Tonic Labyrinthine Reflex (ATLR)
  • Tonic Lumbar Reflex
36
Q

STNR (Symmetrical Tonic Neck Reflex)

A

“seal stretch posture”
• Neck flexion results in
• UE Flexion
• LE Extension

  • Neck extension results in
  • UE Extension
  • LE Flexion
37
Q

ATNR (Asymmetrical Tonic Neck Reflex)

A

“Mr. Olympia posture”
• Neck rotation (or lateral flexion) results in

  • Flexion of the “skull” limbs
  • Extension of the “jaw” limbs
38
Q

Tonic Labyrinthine Reflex*

A

“like a ragdoll”

• Head position in space

  • Supine*
  • Maximal extension
  • Prone*
  • Minimal extension
39
Q

ATLR (Asymmetrical Tonic Labyrinthine

Reflex)

A

• Head position in side-lying facilitates

  • Ceiling side
  • UE and LE flexion
  • Floor side
  • UE and LE Extension
40
Q

Tonic Lumbar Reflex

What is it and what posture is it similar to?

A
  • Receptors in lumbar spine
  • Trunk Rotation Facilitates:
  • Extension UE and Flexion LE
  • Opposite side
  • Flexion UE and Extension LE
  • Same side
• Tennis Serve:
• Body is right rotated
• RUE (elbow) flexion, RLE (hip)
extension
• LUE extension, LLE flexion
41
Q

Postural Reflexes

• Any or all of these reflexes may become grossly exaggerated in the
presence of

A

CVA/TBI

• As compared to normal subjects.

42
Q

Postural Reflexes

• Latency Period:

A

interval period between onset of stimulus and onset

of response

43
Q

Postural Reflexes

• Summation effect:

A

how you set a patient up can either increase or
decrease a given response
• .i.e. with supine with neck flexion will increase LE extensor response (STNR)
but we often ask for hip/knee flexion in this position and then wonder why it
is so difficult for the patient.

44
Q

Use of postural reflexes

A
  • For reinforcing treatment/particular movement
  • To create and set up background tension for movement.

Gradually wean patient from influence of reflexes
• i.e. working on elbow extension

45
Q

Use of ATNR*

A
  • Head turned to side looking for extension
  • Head in neutral
  • Head to opposite side looking for elbow extension
46
Q

Marie-Foix Reflex

What is it and what is it not?

A 
• NOT a postural reflex
• Quick movement into
plantarflexion and inversion
causes a reflex dorsiflexion at the
ankle and flexion of the hip
47
Q

Clinical Application of the Stages

• OVERALL our job is

A
  • To help the patient progress thru the recovery process

* To facilitate as normal and functional movement as possible

48
Q

Breaking out of Synergy:

What do do and what do do when providing resistance

A
  • Quick stretch to facilitate response
  • Manual contact for guidance
  • Resistance may be used to reinforce a response
  • Elicit overflow
  • Proximal to distal
  • Stronger to weaker
49
Q

When Breaking Synergy:

What should you do

A
  • Contraction Type
  • Isometric
  • Eccentric
  • Isotonic

• Easier for Pt with CVA to hold a contraction/position than to have to
move it.

50
Q

Long Term Goals of Synergy Treatment

A

• To try and get patient out of abnormal synergy pattern into something
more desirable
OR
• To change it to make it more functional.

51
Q

Treatment Example

Facilitating trunk control

A 
- In sitting, hold affected
elbow
- Actively shift weight
and facilitate trunk
forward and obliquely
forward
52
Q

Stroke Rehabilitation Assessment of

Movement (STREAM)

A

Outcomes Measure to assess recovery of movements after stroke
- Incorporates movements from the Brunnstrom’s recovery stages
Includes:
- Voluntary Movement of the limbs (20 pts for UE, 20 pts for LE)
- Basic Mobility (30 pts)
- Max score 70; higher score indicates more normal movement

53
Q

What is NDT?
What is the goal?
Used primarily with? (2)

A

The Bobath Approach
• A therapeutic approach to the assessment and management of dysfunction in people with neurological impairments
• The ultimate goal: To maximize the person’s functional ability.
• Developed to be used primarily with:
• Children who have cerebral palsy (CP)
• Adults with cerebral vascular accidents (CVA)

54
Q

Goals of NDT

A

• Provide patient with the sensation of normal movement by inhibiting
abnormal postural reflex activity

55
Q

Key Elements to NDT

A
  • Alignment
  • Handling
  • Placing
  • Practice
56
Q

Key Elements to NDT - ALIGNMENT

A

Postural Control

• Maintain alignment ex:correct sitting alignment
• For the functional task
• Vertical relationship between
body segments to oppose gravity
• Create a stable reference frame
for extremities & head.
57
Q

Key Elements to NDT - HANDLING***

What is it?

A 
A process in which a therapist puts
his/her hands on a patient in a
specific region (key point of
control) to facilitate a targeted
movement
58
Q

Key Elements to NDT - HANDLING***

Observation:

A 
• Observation:
• Use your eyes to scan the whole
person
• Your eyes will also help you to
communicate with the patient, so
you need to arrange yourself as a
handler to give and take feedback
visually

• YOUR EYES NEVER NEED TO BE
WHERE YOUR HANDS ARE.

59
Q

Key Elements to NDT - HANDLING***
• Where do you place your hands?
• Handle through:
Key points?

A

Dependent on desired movement
outcome
• Offers patient feedback and
element of control.

• Handle through:
• Muscle: in correct synergies
• Bone - to maintain better
alignment or disallow movements
extraneous to the desired
movement outcome.
• The choices you make here are
directly related to your patient's
problems, tendencies in
movement as based on those
problems.
• The key points that you choose
should make movement easier!
60
Q

Key Elements to NDT - HANDLING***

Open Handed Approach

A 
• Cover greater amount of body
surface
• NO Grasping
• Elicits counter resistance
Move Slowly!
61
Q

Key Elements to NDT - HANDLING***

Soft Hands

A 
• Less noxious input
• Build input gradually
• More natural output
• Using
• skin receptors for facilitation or
inhibition
• Joint receptors (approximation)
Move Slowly!
62
Q

Key Elements to NDT - HANDLING***

When to use manual cues and do not…

A

• Only use manual cues if visual, verbal and all other forms of input are
not working or are not enough!

• Do not overuse manual cues!!!!

63
Q

Key Elements to NDT - HANDLING***

Inhibition

A 
• A technique utilized to decrease
excessive tone and movement. 
- Restore normal alignment in the
trunk and extremities by
lengthening spastic muscles
• Stop unwanted movements and
associated reactions from occurring
• Teach methods for decreasing the
abnormal posturing of the arm and
leg during task performance.
64
Q

Key Elements to NDT - HANDLING***

Facilitation

A 
• A technique that is utilized to
elicit a voluntary muscle
contraction.
SEQUENCING-
• Weight bearing with control precedes
non-weight bearing movement
without control.
• Isometric-eccentric-concentric.
-Progression of activity in skeletal
muscle that moves from easier to
more difficult.

• Proximal to distal key points.
-To withdraw your feedback or control
over the movements in a gradual way

• Small ROM to larger ROM of
movement with control
- Once pt. has control in small
movement – increase ROM

• Slow to fast movement
- Once pt. has control in slow – increase
speed

65
Q

Key Elements to NDT - HANDLING***

Key points

A

• Specific handling of certain areas
of the body

• Influence and facilitate posture,
alignment, and control.
• Shoulder
• Pelvis
• Hand
• Foot/ankle
• Toes
• Fingers/wrists
66
Q

Key Elements to NDT - Placing

Reflex inhibiting postures (RIPs): what is it?

A

• Designated static positions that Bobath
found to:
• Inhibit abnormal tonal influences and reflexes.

67
Q

Key Elements to NDT - Placing

Reflex inhibiting postures (RIPs): of UE

A

shoulder in ER, elbow in extension

68
Q

Key Elements to NDT - Placing

Reflex inhibiting postures (RIPs): of LE

A

hip in abduction, ER, and extension; knee
in extension, ankle and toes in DF, great toe in
abduction (therapist places finger btwn great toe
and second toe)

69
Q

Key Elements to NDT - Placing

Reflex inhibiting postures (RIPs): of trunk

A

rotate the shoulder girdle against the

pelvis

70
Q

Key Elements to NDT- Practice

A 
• The act of moving an extremity
into a position that the patient
must hold against gravity
• Patient must be taken care of
24/7 if carryover is expected
• Practice increases retention
• Functional
• Sensory functional
• Sensory-motor experiences
71
Q

Facilitate Trunk Control

Rolling:

A 
use trunk righting
reaction and protect the
affected arm
- Head and trunk stay in midline
- Hold affected arm by the elbow or
the wrist
72
Q

Facilitate Trunk Control

Supine-to-sit

A
  • Maintain trunk elongation
  • Weight bear through UE as
    tolerated
73
Q

Facilitate Trunk Control

Sitting

A 
Sitting (upright posture
indicates anti-gravity control)
- Upright sitting posture (equal
weight bearing) and elongate
trunk on the affected side
- Sitting balance (use protective
extension of arms)
- Facilitate trunk control laterally,
forward/backward, and
rotationally (use arms)
74
Q

Facilitate Trunk Control

Others

A
  • Consider quadruped, but difficult for an elderly person
  • Consider kneeling, half kneeling
  • Sit to stand
75
Q

Preambulation Skills

A 
- Ankle, knee, and hip control in
bed
- Bring the leg into flexion and hold
at different angles
- Prevent hip adduction and internal
rotation
  • Bridging exercises
  • Facilitate control of the affected
    hip
  • Avoid lifting the trunk too high
  • Transfer (Mat to Wheelchair)
    from the affected side
  • LE control in sitting (both feet on the ground)
  • Facilitate active knee and ankle control in sitting
  • Flex the affected knee beyond 90 degrees
  • Swiss ball exercises (in sitting) to facilitate upright posture
  • Standing posture (equal weight bearing)
  • Weight shifting in standing with different base of support and feet
    positions
76
Q

Ambulation Skills

A
  • Facilitate affected leg to bear weight
  • Move the sound leg forward/backward
  • Standing will cause weight bearing and compression→ will increase
    the extensor tone of the affected leg
  • Facilitate pelvic movement (prevent protraction or retraction)
77
Q

Cueing hip extensors during gait

A 
- Cue hip extension during mid to
terminal stance
- Cue may include assist for forward
progression of trunk over stance
limb
78
Q

Cueing hip flexors to initiate swing

A
  • Tap over hip flexor muscle/tendon at

toe off. Timing is important!

79
Q

Cueing the pelvis to rotate

A 
- Walk backward in front of the
patient or behind them
- Therapist’s hand should be on
ASIS
- “Push into my hand” cue given
at initial swing

CVA (2 decks)

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