Traditional Approach- Brunnstrom

Question 1

Brunnstrom original approach

Answer 1

To take a patient from presenting level of neuromuscular development, and progress from sub-cortical to cortical control of movement. This is done by facilitating synergies early on, then using various techniques to “modulate activity.”

Question 2

original goal

Answer 2

Goal is develop isolated voluntary control.

Question 3

What did research say about synergies?

Answer 3

reinforcement of synergies is rarely used now- research has shown that reinforced synergies are difficult to change.

Question 4

Associated Reactions

Answer 4

an involuntary & automatic movement of a body part as a result of intentional active or resistive movement of another body part.

UE: flexion of good UE evokes flexion of weak
UE: extension of good UE evokes extension of weak
LE: flexion evokes extension
LE: extension evokes flexion

Question 5

Ramistes Phenomenon

Answer 5

The involved LE will abduct/ adduct with applied resistance to the uninvolved lower extremity in the same direction.

Abduction evokes abduction
Adduction evokes adduction

Question 6

Homolateral Limb Synkinesis:

Answer 6

A flexion pattern of the involved UE facilitates flexion of the involved LE.

Question 7

Souque’s Phenomenon:

Answer 7

Raising the involved UE above 100 degrees with elbow extension will produce extension and abduction of the fingers.

Question 8

Limb Synergies

Answer 8

groups of muscles which, when activated reflexively or voluntarily, are firmly linked together.

as a patient attempts to move at one joint, the entire extremity will move in the activated synergy pattern.

Result: patient is not able to perform isolated joint movements.

Question 9

Components of Basic Synergies

important

Answer 9

Gross Flexion UE
Gross Extension UE
Gross Flexion LE
Gross Extension LE

Typical Posture is a mixture of the Movement synergies.
See OSullivan Text book p. 721

Question 10

Gross Flexion UE

Answer 10

retraction and/or elevation of the shoulder girdle
abduction of the shoulder to 90 degrees
external rotation of the shoulder flexion of the elbow to 90 degrees
full supination of the forearm

Question 11

Gross Extension UE

Answer 11

protraction and/or depression of the shoulder girdle
adduction of the upper extremity in front of the body
internal rotation of the shoulder
full extension of the elbow
full pronation of the forearm

Question 12

Gross Flexion LE

Answer 12

abduction and external rotation of the hip
flexion of the hip
flexion of the knee to 90 degrees
dorsiflexion and inversion of the ankle
extension of the toes

Question 13

Gross Extension LE

Answer 13

adduction and internal rotation of the hip
extension of the hip
extension of the knee
plantarflexion and inversion of the ankle
plantarflexion of the toes, sometimes extension of the great toe

Question 14

What do the 7 stages describe

Answer 14

tone, reflex activity, and volitional movement.

Question 15

Stage 1: Flaccidity

Answer 15

No voluntary or reflexive activity is present in either involved limb. Associated reactions cannot be elicited.

Question 16

Stage 2: Reflexes and Synergies Appear

Answer 16

Minimal voluntary motion may be present in this stage where the basic movement synergies or some of their components may be elicited reflexly as associated reactions. Spasticity begins to develop: first seen as resistance to passive stretch.

Question 17

Stage 3: Spasticity increases, voluntary synergies appear

Answer 17

Spasticity becomes more marked. The basic movement synergies may be performed voluntarily, although full range of all components may be lacking. Many patients stay in this stage.

Question 18

Stage 4: Movements Deviating From Basic Synergies

Answer 18

Movements which deviate from the basic synergies can be accomplished on a volitional basis. Spasticity begins to decline.

Question 19

Stage 5: Relative Independence from the Basic Synergies

Answer 19

The basic synergies lose their dominance over volitional behavior and the patient becomes increasingly more adept at performing movement combinations that differ greatly from the synergies. Spasticity continues to decline.

Question 20

Stage 6: Spasticity Essentially absent

Answer 20

Isolated muscle actions can be performed freely. Coordination is good but awkwardness may appear in movements at high speeds.

Question 21

Stage 7:

Answer 21

Normal motor function is returned

Question 22

Five Goals of Treatment

Answer 22

• To have patient gain voluntary control of the synergy (stage 1-3)
• To inhibit unwanted activity & break away from gross movement patterns by mixing up synergistic components (stage 3 & 4). Use afferent input to inhibit unwanted activity.
• To progress sequentially through recovery stages of the CNS. Work to regain voluntary control.
• To gain voluntary hand control.
• To make exercise functional: incorporate activities of daily living.

Question 23

General principals

Answer 23

Postural reflexes are used as a means to increase or decrease tone in specific muscles. (ATNR, STNR, Tonic Lab)

Associated reactions may be used to initiate or elicit movement in the early stages of rehab.

Stimulating the skin over a muscle by rubbing with fingertips produces contraction of that muscle.

Encourage overflow to recruit active movement on the weak side.

Use of repetition & positive reinforcement.

Visual (mirrors, videotape) & auditory stimulation used to facilitate movement.

**The strongest component of a synergy inhibits it’s antagonist through reciprocal innervation.

A patient will follow the stages of recovery, but may experience a plateau at any point so that full recovery is not achieved.

Movement combinations that deviate from the basic limb synergies should be introduced in stage 4 of recovery.