Brunnstrom Approach

Upper limb treatment

Agnes Kezia M Mallari,\ PTRP

Upper limb treatment
• Based on the stages of recovery

• flaccidity (Stage 1)Background tension in the affected limbs is developed using associated reactions or attitudinal
reflexes or a combination thereof. Volitional effort is then superimposed on the reflexly produced background
tension.
• When the patient is able to initiate movement on a voluntary basis (Stage 3), reflex assistance is withdrawn, and
movement patterns that deviate from synergy are introduced.

• In the following discussion of treatment procedures, it should be kept in mind that associated reactions and
attitudinal reflexes are appropriate facilitators of background tension in the atonic or hypotonic limb, but are
inappropriate when background tension is adequate for volitional movement; that volitional movement in the
direction of the basic limb synergies is appropriate when used to facilitate movement in nonsynergy patterns, but is
inappropriate if used to reinforce or gain full control of all components of the synergies per se; and that resistance
to reflex or voluntary movement is appropriate when it enhances the desired qualitative or quantitative
characteristics of movement, but is inappropriate when it detracts from those characteristics.
Range of motion
• Asssstsnq patsent’s
involved UE while
performing PROM

• Cup tre patsent’s

elbow with your hand:
note to maintain
wrist in slight
extension with the
PT’s sndex psnqer and
middle finger or index
finger and thumb
placed against his
thenar and
hypothenar eminence
Range of motion
• Note to perform a very
gentle passive
movement to avoid
eliciting spasticity and
normalize tone
Range of motion

• Incorporate passive mobilization

of the scapula
Evoking associated reactions

• If the patient is unable to initiate voluntary movements and

spasticity or potential spasticity is present, associated reactions
may be utilized to evoke a background tension in flexor or extensor
muscles in preparation for voluntary initiation of movement.
Evoking associated reactions
• The first associated reaction observed following the onset of hemiplegia usually
occurs in the flexor muscles; extensor responses appear later.

▫ When the associated response is weak, a tensing of the muscles without joint
movement may be observed, but in most instances, if the patient's effort is strong,
some joint movement may be observed, particularly if the eliciting stimulus is
repeated.

▫ Semivoluntary movements may then materialize from an interaction of reflex and

voluntary impulses, and the patient experiences the sensation and satisfaction that
accompanies a voluntary muscular contraction. This is the main purpose of
associated reactions in training procedures. The type of stimulus that elicits the
desired muscular contraction also indicates to the therapist what type of
resistance in other parts of the body is most effective to reinforce voluntary
movement
Shoulder pain
• A considerable number of patients with hemiplegia complain about
shoulder pain when passive shoulder abduction to increase range of
motion is attempted.
• But nearly complete range of abduction without pain may be
obtained with the patient's cooperation, that is, if a combination of
active and passive movements is utilized.
Shoulder pain
• Shoulder girdle movements- elevation, lowering, retraction,
protraction-are first stressed; then, in conjunction with these,
painless glenohumeral movements of increased range become
possible.
Shoulder pain
• Forceful shoulder movements with no regard to pain are ill advised
because they are of more hindrance than help.
• Patients who have experienced severe pain from a forced passive
range of motion procedure may become very apprehensive, even
hostile. In such patients, a protective mechanism, characterized by
strong tension in the pectoralis major muscle and in other muscles
surrounding the shoulder joint, may develop, which makes attempts
at shoulder mobilization doubly difficult.
Techniques for painless shoulder
movements
• The procedure begins with shoulder flexion, first performed bilaterally,
then unilaterally.
• The arm is supported with the elbow flexed. If the patient is unable to
elevate the shoulder girdle voluntarily, the movement is assisted by
upward pressure on the elbow. Simultaneously, the physical therapist may
use her free hand for percussion or cutaneous stimulation over the upper
trapezius muscle: When the muscle responds, a lengthening contraction is
first requested ("Don't let me push your shoulder down"), then elevation is
repeated--if possible, against manual resistance ("Now pull your shoulder
up toward your ear").
Techniques for painless shoulder
movements
• Shoulder elevation performed actively by the patient tends to evoke
activity in all components of the flexor synergy, particularly if resistance
is applied. It also has an inhibitory effect on components of the extensor
synergy, notably on the pectoralis major muscle.
• This inhibition is utilized by the physical therapist to abduct the arm
gently in small increments each time the patient repeats the movement.
The rhythm of these repetitions is regulated by the therapist's voice
directing the procedure: "Pull up, let go, pull up, let go," and so forth. The
direction of these abduction movements is oblique, halfway between
forward and sideward; the strictly sideward direction is likely to cause
pain and is avoided.
Techniques for painless shoulder
movements
• At one time or another during the elevation procedure, the patient's
attention is drawn to supination of the forearm.
• Note that alternate supination and pronation movements by the physical
therapist have accompanied elevation and lowering all along. Because
supination of the forearm and external rotation of the shoulder are
mutually facilitatory (both belong to the flexor synergy), the two
movements should be combined. External rotation of the shoulder,
required for abduction beyond the horizontal, has thus heen introduced
painlessly, and the stage is set for further elevation of the arm.
• Head rotation toward the normal side usually contributes to relaxation of
the pectoralis major muscle.
Techniques for painless shoulder
movements
• After the arm has been carried well above the horizontal position and no
pain is present, the command "Reach overhead and straighten out your
elbow may be given.
• First, however, the patient must rotate the toward the affected side to
facilitate elbow extension and to allow him to observe the movement.
• The last portion of the procedure should be requested only of patients
who have made sufficient progress

• It is equally effective to employ shoulder girdle retraction and its

opposite movement, protraction, as a starting point for shoulder
mobilization
For next meeting
RONQUILLO, KARL ANDRE URBIZTONDO
AGUELO, MARIA ANNABEL BUHIAN
GALLEGO, ANGELIKA ELISAN
PASAOL, LIANA WAYNE PASPE
• How to guard against subluxation. Present
procedures and rationale by brunnstrom.
CHINGKAW, JEREMY DUANE TAN
DAWIS, ANNIA MARIAN CATULAY
HERMOSO, ALYANA MARIA MIKHAELA
REYES, KIMI CRUZ
• Present procedures and rationale by Brunnstrom in
reinforcing voluntary abduction of the UE.
PEÑA, FRANZ KRISTIAN OMPAD
TORNO, PIOLO CALDERON
FAJARDO, GLIZELLE JANE LU
SUIZO, PHOEBE KAYE WATIN
• Present procedures and rationale by Brunnstrom in use of
proximal traction response
BOLOTAOLO, KAEL BERNARD ASTRONOMO
SY, DAN JACOB LIM
PACULBA, TRISHA MAE ENORIO
• Present procedures and rationale by Brunnstrom in
bilateral contraction of the pectoralis major muscle

• (waist squeeze)
LISTON, PAOLO EMMANUEL DELA CRUZ
CARREON, MACEY CHIU
ESPIRITU, MARIA LIANA ALMACEN
ZAPANTA, CONELLE MICHAELE MENDEZ
• Present procedures and rationale by Brunnstrom in
bilateral contraction of the pectoralis major muscle

• (rowing exercise)
ITALIA, JEHU MAR ELMER DIAMANTE
RUEGO, ROBERT IAN
NERI, NICOLE ANDREI
TORRALBA, VITA CHARUVALE ALAG
• Present procedures and rationale by Brunnstrom in
bilateral contraction of the pectoralis major muscle

• (weight bearing)
ALCANTARA, CHRISTIAN ALFONSO STA. ANA
CABINGAS, XYLDENAE MARIEL LEGION
DOTIMAS, CHRISTINE JOY SOLOMON
SAQUIAN , SHANNAH KELLIE MAGHARI

• Present procedures and rationale by Brunnstrom in

early training of serratus anterior
FANTONE, JOHN CLYDE DUGA
ALAGAO, ALICE MARIE QUIJANO
LABIANO, JURENE CORTEZ
PEÑANUEVA, AUDREY ROSE INOJALES

• Present procedures and rationale by Brunnstrom

wren trere ss wstrdrawal op trerapsst’s asssstance