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1. Trail and error 2. Hierrachical control 3. Reflex model

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Neurophysiological Approach based on clinical observation of hemiplegia (3)

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Attemps to affect the nervous system intself

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Movement Therapy

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1. Coupling of muscles in orderly way for purposeful movement 2. Can be recombined

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Normal synergy (2)

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Condition of motor/sensory defecit on one half of the body that is OPPOSITE the side of brain lesion

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Hemiplegia

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1 - stereotypes 2 - can not be recombined 3 - primitive 4 - automatic 5 - reflexsive 6 - obligatory

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Post Stroke Synergies (6)

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Flexor and Extensor synergies of the UE and LE

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Pathologic Synergy

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When we start to see activity come in first it comes via dominant components *As flaccidity resolves the dominant component of synergy are the first to show increased tone*

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Dominant Components

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Elbow flexion! -retraction/elevation of shoulder girdle -shoulder ER -shoulder ABD -elbow FLX -Forearm supination

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Dominant Components: (UE flexor synergy)

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-retraction/elevation of shoulder girdle -shoulder ER -shoulder ABD -elbow FLX -Forearm supination

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-UE flexor synergy

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Pec Major ^shoulder ADD (IR) ^Pronation

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Dominant Components: (UE Extensor synergy)

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-fixation of shoulder in protracted pattern -shoulder IR -Add of arm across body -Elbow EXT -Forarm pronation

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-UE Extensor synergy

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Hip Flexion

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Dominant components: (Flexor Synergy LE)

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-Hip Flexion -Hip ABD. ER -Knee flexion -Foot DF, Inversion

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-Flexor Synergy LE

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Knee extension

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Dominant components: (Extensor synergy of LE)

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-Hip extension -Hip ADD, IR -Knee EXT -Ankle PF and Inversion

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-Extensor synergy of LE

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Perpetuates synergy imbalance

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Reciprocal Inhibition

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-Shoulder ADD (IR) -Elbow FLX -Pronation

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Typical posture of UE (3)

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EFFORT

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What increases tone

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Elicit normal motor activity by reflexes ***You want any movement because reflexes are needed before normal movement can occur

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How can you elicit synergies? Why would you want to do this...?

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Encourage movement by any means!!

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Brunnstrom Technique

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Synergy (with use of reflexes)

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Facilitate movement via.....

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1. Symmetric Tonic Neck = FLX facilitates flexion of UE and extension of LE -Extension facilitates extension of the UE and flexion of the LE 2. Assymmetric Tonic Neck = Extension of the jaw side and flexion of the skull side

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Reflex Facilitation (2)

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EFFORT! (BOS, COG, distractions, difficulty of task)

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How to recruit activity without all-or-none

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Can recruit without all-or-none synergy patterns

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Pull down effort

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Supine facilitates extension Prone facilitates flexion

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Reflex Facilitation -Tonic Labyrinthe

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UE flexion --> Flexion and extension --> Extension LE opposite in sagittal plane LE symmetric in frontal plane

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Reflex Facilitation -Associated Reactions

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***Pathological but GOOD for Brunnstrom Forced involuntary efforts will elicit associated reactions (ex: cough forcefully and arm moves)

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Associated Reactions

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1. Souque's Finger Phenomenon = raise shoulder and palm of hand to 90 degrees, get finger extension 2. Tonic Thumb Reflex = hand gripped, ABD metacarpal from hand (relax flexors) 2. Homolateral limb synkinesis = same side arm and leg. Same movement --> to get UE ADD do LE ADD

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*Useful associated reactions (3)*

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WB to promote co-contraction and facilitate extension Proximal traction or quick stretch to facilitate flexors

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Facilitation -how to promote extensors -how to promote flexors

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1. Flaccidity 2. Synergy present and some spasticity 3. Voluntary control over some components of synergy and spasticity peaks (not always all-or-none) 4. Out of synergy movement and spasticity declines 5. Synergy losing dominance 6, Individual joint movement and spasticity essentially gone 7. Recovery

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Stages of Recovery (7)

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Critical Sensory impairment is critical to the prognosis for functional recovery

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Sensory Involvement is _______ -why?

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Synergies (reflexes) --> Gross mvt --> Proximal mvt --> Distal movement

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Recovery from Stroke --> --->

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SUCCESS

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Movement Therapy needs _____

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Small fairlure is monumental, looks for alternatives

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Failure is detrimental, why?

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Understand how hard the task is and is it in their capacity?

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How to build success?

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1. Avoid posturing 2. Position out of dominant component of synergies 3. Early mobility a. bed mobility --> roll toward affected side b. balance training --> evoke reflexsive response

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Treatment Approach (2)

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A normal sequence and the voluntary control over the basic synergies is required for prerequistie to control over more advanced movement patterns

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Stages of Recovery are

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Synergies

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Use reflexes (elciting a flexor withdrawl stimulus) to get

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Encouring voluntary initiation

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Foundation of treatment

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NO

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Do you have to perfect the skill before moving on to the next?

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1. uses reflexes and associated reactions to stimulate motor activity 2. superimposes volitional activity 3. when pt can iniate on own withdrawl reflex support 4. move to out of synergy patterns

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4 notes on movement system

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1. Isoltate knee flexion 2. Combine knee flexion with hip extension

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2 ways to move out of synergy

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Normally gait is automatic -don't walk in paralel bars, walk when you are ready! ***Automating Patterns

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Brunnstrom approach to gait (basic idea)

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Don't walk in the early stages post stroke, do not want to allow pt to develope bad patterns *instead, do pre-gait activities*

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Explain automating patterns

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1. Hip flexion and facilitate voluntary control of hip 2. Work on DF activation and then control of DF out of synergy and in particular with knee extension as you need it in gait 3. Varied heights of seated surface to change amt of hip extension while working on distal component control 4. Sit to stand activiteis and WB 5. Standing in dynamic exercises - to promote bilateral ABD 6. Plantigrade 7. Mini squats 8. Weight shifts and trunk rotation

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Pre-gait Activities (8)

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1. Don't walk early (stage 1-3) post-stroke 2. Gait preparation early] 3. Gait w/out Assistive device 4. No verbal cues --> gait is automatic

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Brunnstrom Approach to Gait (4)

6 – Brunnstrom – Movement Therapy – Flashcards

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