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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 Brunnstrom’s 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 Systems Theory Hierarchical Theory Reconstruction of the NDT approach 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 Principles of treatment: children with cerebral palsy • 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 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 Hierarchical brain organization (Reflex model) NEW THEORY Systems Model Normal postural reflex mechanism as the Postural control is learned together with basis of normal movement 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. Brunnstrom’s 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 patient’s 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: Flexor • Shoulder: Synergy • Elbow: • Forearm: • Scapula: Extensor Synergy • Shoulder: • Elbow: • Forearm: retraction and/or elevation abduction and ext rotation flexion supination protraction and /or depression adduction and int rotation extension pronation Basic limb synergies: UE • Hip: Flexor Synergy • Knee: • Ankle: • Toe: • Hip: Extensor Synergy • Knee: • Ankle: • Toe: flexion, abduction, and ext rotation flexion dorsiflexion extension extension, adduction, and int rotation extension plantarflexion flexion Mixed synergy: UE Strongest Flexor Extensor elbow flexion shoulder adduction internal rotation Next strongest Weakest forearm pronation shoulder abduction external rotation elbow flexion Mixed synergy: LE Flexor Strongest hip flexion Weakest hip abduction external rotation Extensor hip adduction knee extension ankle plantarflexion ankle inversion hip extension 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 stimulus response Neck flexion Upper extremity flexion Lower extremity extension Neck extension Upper extremity extension Lower extremity flexion – Asymmetric TNR stimulus Neck lateral rotation response Jaw side: upper extremity extension lower extremity flexion Skull side: upper extremity flexion lower extremity extension • Tonic Labyrinthine Reflexes stimulus response supine Limbs tend to move in extension prone Limbs tend to move in flexion • Tonic Lumbar Reflex 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 • Raimiste’s 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 • Soque’s 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 •Individual joint movement becomes possible •Coordination approaches normalcy •Spasticity disappears: individual is more capable of full movement patterns Stage 6 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). Brunnstrom’s Movement Therapy in hemiplegia: A Neurophysiological Approach (2nd ed). Philadelphia, J.B. Lippincott Company.