Objectives ee After: ‘studying this chapter, the learner will be able to: nat'underlie Movement 1. Understand the premises th Therapy for stroke patients 5, Understand thé treaiment procedures to facilitate "moverén contol tusk ond upper este {,: otthemiparetic patenis using his opproach. 6 Suggest functional ceive suitable to encouto ‘the-Practice ‘of movement” conrol “ot yarious = stages of recovery... HISTORY Brunnstrom, a physical therapist, was particularly concemed with the problems of patients following stroke. Her approach to their treatment has. given, therapists insight into the behaviors of a master elini- cian. In developing Movement Therapy, Brunnstrom ‘experimented by applying, in a trial-and-error fashion, procedures that she derived from mator control litera- ture or from observations of patients. She paid careful attention to the patient's motor and verbal reactions to each procedure, interpreted those reactions in light of her knowledge of motor control and development, and adjusted the procedure accordingly. Successful proce: dures were replicated patient to patient. The principles of Movement Therapy and the ‘evaluation and treatment procedures presented here are summarized and adapted from Brunnstrom (1970), which describes her approach in detail. PRINCIPLES ‘The assumptions that underlie the Movement Therapy approach are as follows. a 1. In normal motor development, spinal cord and brainstem reflexes become modified and their compo- nents rearranged into purposeful movement through the influence of higher centers. Because reflexes and whole-limb movement patterns are normal stages of development and because stroke appears to result in “development in reverse,” reflexes and pri 24 Remediating Motor Control and Performance 463 2 7 4C Movement THERapy or BRUNNSTROM Catherine A. ‘Trombly ment patterns should be used to facilitate the recovery of voluntary movement poststroke. Brunnstrom (1956) believed that no reasonable taining method should be left untried and stated, “It may well be that a subcort- cal motion synergy which ean be elicited on a reflex basis may serve as a wedge by means of which a limited amount of willed movement may be learned” (p. 225), 2. Proprioceptive and exteroceptive stimuli can bie used to evoke desired motion or tonal changes. 3. Recovery of voluntary movement poststroke proceeds in sequence from ‘mei patterns are called limb synergies. Synergy, in this sense, refers to patterned movements of the entire limb in response toa stimulus or to voluntary effort. 4. Newly produced, correct motions must be practiced to be learned. 5. Practice within the context of daily activities ‘enhances the learning process. The principles of Movement Therapy are listed below. ineh related to the stimulated area, 3, When voluntary effort produces, or contributes to, a response, the patient is asked to hold (isometric) the contraction. If successful, he is asked for an Scanned with CamScanner 1g movement. Resistance (a propriocep- tive stimulus) promotes a spread of impulses to ‘ther muscles to produce a patterned response (associated reaction), whereas tactile stimula tion (exteroceptive) facilitates only the musclesrinciples and Practices ‘464 Section IY) Treatment ._Faelitation is reduced ot dropped out as quickly ‘as the patient shows Facilitation procedures are dro in order of their stimulus-response binding. Rellesesy in hich the response is stereotypically bound to a ceitain stimulas, are the ost primitive and are , Responses to extero- seolyped, and there= ated last, No pritmi= A reactions, are 6. Emphasis is placed on willed movement to overcome the linkages between parts of the synergies; willed ‘movement means that the patient is trying to accom plish it It helps if the person is asked to do @ familiar movement, such as reaching for a soft drink can, 7. Correct movement, once elicited, is repeated to leam it; practice should include functional activi- ties to inerease the willed aspect and to relate the sensations to goal-directed movement. EVALUATION Evaluation in the Brunnstrom approach includes determination of the following: 1. The patient’s sensory status; 2. The level of recovery of voluntary motor control; 3. The effect of tonic reflexes on the patient's move- ment; 4. The effect of associated reactions on the pa- tient’s movement. Sensation ‘The sensory evaluation precedes the motor evalu- * ation. er B for evaluation procedures evaluation guide choice of facilitation modalities that the therapist may use to facilitate movement or alert the therapist to encourage the patient to substitute visual feedback for lost movement or po Results of the sensory Level of Recovery of Voluntary Movement Table 24C. 1 lists the six stages of recovery of the proximal upper extremity and hand and the three stages af recovery of the wrist that Brunnsirom (1970) identi- average, proce ie Au eke UN am oy a Uh008 a ere are no reliable ways 0 predicy are eel scoser volmary ovement which will not. ae le " eae singe freer Ps mie ao ogially comfortable ahysienly an re alton (Table 24C.2) vet epee ne the_patien’ level of mater ar ol 1d the patient's capabilities ation is used during the waluation, Each motion jis demonstrated to the patient, “i Ie faa with his unaffected extremity before he aitempis it with his affected one, s0 the therapist can be certain that the person understands the request. Instructions should be given in functional terms; For ccample, to test the flexor synergy of the upper fatrenity, say “Touch behind your ear” and for the ce ey gy each otto touch Your opposite] nee” (Brunnstrom, 1966). The patient's ability to do the requested movement is recorded according t0 the percentage of fange of motion that he completed. For trample, when asked for a flexor synergy response, if the patent is able to bring the hand only as far as his moith rather than to his ear, the therapist may observe that he has complete elbow flexion (100%), ‘about 45° of shoulder abduction (50%), supination to midrange (50%), and minimal external rotation (25%). When the patents response is incomplete, a in this ‘example, it may be necessary to observe the patient's repeated attempts to determine the speeific weak areas of the synergy or movement pattern and to decide on the rating. A Polaroid photograph, taken in a standard- ized way, would provide’clear documentation of the patients abilities before and after a treatment program. "A patient is reported to be in the stage at which hhe is able to accomplish all motions specified for that stage. Because progress is gradual, there will be instances when the patient is in transition between beginning to be able to do the motions of the next stage, many therapists would record his level as “2 going on 3” or “3 going on 4,” ete. The upper and lower extremities as well as the hand may all be in different stages of recovery at given time, Brunnstrom’s evaluation is valid in that it reflects observations made by Twitchell (1951) of the recovery process of 118 patients who had suffered strokes, onset of which ranged from 5 days to 5 years before ‘observation as well as her own observations of 100 patients (Brunnstrom, 1970). A modified, better-de- fined version of the Brunnstrom and Fugl-Meyer evalua- tion was used to evaluate recovery of the lower limb of 23 poststroke patients (Clarke et al., 1983). The stage Scanned with CamScannerTable 24€.1._ Recovery Stages of the Upper Extremity 24 Remediating Motor Control and Performance 465 2 Cnr ie an 2 TET se mn (smal range of maton) fol ond sphere grsp (owkoward) Saneaieeeia* tecten ‘ tery hager exenion ong of moon Individual fnger movements Table 24€.2._ Hemiplegio—Classification and Progress Record: Upper Limb Nome Age Dote Stage 1. No movement ntsed or eliced: Raced Dote of ese Side olteced 2. Synergies or componen!s maybe eiced;spotciy developing. Nol extent of response: Fear smergy Extensor synergy flexor smear copula elevation Scopuoretocion Shoulder abduction Shoulder external reton bow Peson Fereor supination Extensor synergy Seopulorproracion Elbow extension Foreotm pronation 3. Synercies or components nitoed voluntary sposicily morked. Pevcent Active Joint Ronge Percent Acive Joint Range ‘Shoulder adduction ond inlernal rotation (pecorlis major) Scanned with CamScanner46. Section IV. Treatment Principles and Proctices red Toble 24C.2._ Conti 4, Mowe ce. Hond behind back ©. Raise crm to 90" forward Resin € Pronoton supination, elbow ot 9 Rexion IIT 5, Relative independence of bese yer ‘0. Roite erm t 90 ebeuction 1 Raise orm forward and ovesheod €. Pronction supination, elbow extended (describe motion) TEE orp 2. bow extended bow fled 5. Weis flexion end erension, ft closed 2, Elbow extended. Elbow flexed | Digits 1 Feeitiy 0 voutory movement 2, Lille or no active finger Rion 3. Mass grosp or hock grosp 5.0, Pelmar prehension © Spherical group (owkorord) 4. Ghindiol group (onkword) 6.0. All pes of grasp wih improved ill ITT TA of recovery was strongly corelated to key aspects of 0.60 100.88), which suppons its validity. No ‘conceming the reliability of Brunnstrom's version of the evaluation, but the reliability can be assumed to be low, because the rating scales are not ‘operationally defined. To improve reliability, Fugl- Meyer et al. (1975) operationally defined 50 details of joint motion of the limbs, across the six levels of recovery. The Fugl-Meyer Motor Test uses an ordinal level scoring system in which each detail is rated 0 (cannot be performed), 1 (can be partly performed), or 2 (can be performed faultlessly). Total scores range from 0 (flaceidity) 10 100 (normal motor function). Intrarater and interrater reliability of the upper ex- ‘emily subtest (33 items) were determined to be strong (r= 0.99) and significant (Duncan, Propst, & Nel- son, 1983). Because recovery proceeds sequentially, once the sens devitng fom basic series spastic decreasing cy wring, 4.0, Lotro prehension; release by thunb movement 1, Semivolunlory mors extention anal renge ef motion i, Voluntry finger exension ful range of mation € Inivdvol finger movements (do desterty tes) 6, Movement! coordinoed ond near somal; spstciy mimel. 6, Wis eircumducion (sbi forearm) 1, Voluntary moss exlention—oriblerongeof mation stage of recovery is identified, the short-term goal becomes the next step in the recovery sequence. Tonic Reflexes Tonic reflexes are assessed to determine whether ‘The primitive reflenes that may be present include the symmetrical and asymmetrical tonic neck reflexes, tonic labyrinthine reflexes, and tonic lurabar reflexes. With the exception ofthe tonic lumbar reflexes, the evaluation ofthese reflexes was described in Chapter 7, ‘The tonic lumbar reflex is elicited by helping the patient rotate his upper trunk in relation to his pelvis. Ifthe reflex is active, fexor tone increases inthe upper extremity and extensor tone in the lower extremity on the side toward which the trunk is turned. Simoltane- Scanned with CamScannerand exor tone in i ‘ssoclated reactions are seen in the in- Pi Atremities of stoke patents when other pars ol ly are resisted during movement or an effort to move is exerted. Associated reactions are evalu. ated to determine which could be used to fuelitate movement when no voluntary movement exists. They are more easily elicited when spasticity is present Associated reactions scen in stroke patients and how to evoke them are as follows volved ext 1, Flexor synergy in the involved upper extremity is elicited by applying resistance o shoulder elevation ar elbow flexion ofthe noninvolved upper exteity 2. Extensor synergy in the involved upper extremity is elicited by applying resistance to horizontal ad duction of the noninvolved up abduction or adduction of the noninvolved extremity evokes the same motion of the involved extremity. 4. Resistance to flexion of the noninvolved leg causes ‘extension of the involved extremity, and resistance to extension of the noninvolved side causes Alexion of the involved extremity., 5. Resisted grasp by the noninvolved hand causes a grasp reaction in the involved hand.y 6. Flexor movement or tone may be elicited in the involved arm when the patient attempts to flex the leg or when leg flexion is resisted. This reaction is called homolateral synkinesis, __ Basi Limb synergies may be elicited us associated reactions or may occur as early stages of voluntary conteol when spasticity is present. When the patient initiates a movement of one join, all muscles that are linked in synergy with that movement automatically contract, causing a stereotyped movement pattern, In the upper extremity, the flexor synergy is composed of scapular retraction and/or elevation, shoulder abduction and external rotation, elbow flexion, and forearm supination. Position ofthe wrist and fingers is variable. Elbow flexion is the strongest component Limb Synergies 24 Remediating Motor Control and Performance 461 (be cid) Soul cena eh ‘weak, although it is not considered part of the flexor of the extension synergy; consequently, shoulder hori- cnc rfc anton ete inst pp te elt. Pion weak component. Teed nvemiy flexor oyengy wl de velop tec caters energy, Wien th Be cera ete Reson a ene oy cergies sometimes combine to produce the typical upper und internally rotated with the elbow flexed, forearm seat teint gem fee ‘The lower extremity flexor synergy is composed flexion, abduction, and extemal rotation; knee flexion; dorsiflexion and inversion of the ankle; and dorsiflexion of the toes. In this synergy, hip flexion is the strongest component, whereas hip abduction and ‘The lower extremity extensor synergy is com- posed of hip extension, adduction, and internal rota- tion; knee extension, plantar flexion and inversion of the ankle, and plantar flexion of the toes. Hip adduc~ tion, knee extension, and plantar flexion of the ankle with inversion are all strong components. Weak compo- nents of this synergy are hip extension, hip internal rotation, and plantar flexion of the toes. Note that ankle inversion occurs in both lower extremity syner The lower extremity extensor synergy is domi- nant in a standing position, because of the strength of this synergy combined with the influences of the posi- tive supporting reaction and stretch forse against the sole of the foot that elicit plantar flexion, TREATMENT — ‘The focus of treatment is the recapitulation of normal movement developmentally from its reflexive base to voluntary contrl of individual motion that can be used functionally. _ Rehabilitating Trunk Control Some patients with hemiplegia may have poor trunk control and may requite training to enable them Scanned with CamScanner“tet Section IV Treatment Principles and Practices to bend over to retrieve an abject from the floor or 19 res their lower extemities. To elicit balance te Sonees the patient is gently pushed in forward, backs sratd, and sidesto-side directions. At first, emphasis is fiven to promoting contraction of trunk muscles onthe involved side by pushing the patient off balance toward the involved side while guarding in ease of poor response. Then, once itis determined thatthe person has that skill, recovery from a push toward the noni solved side is sought. The patient is pushed only to the point at which he is able to hold the position and then regain upright posture and is guarded thr ‘Training then progresses to promote trunk lexi tension, and rotatio Practice in foreard flexion of the trunk is as- sisted. The patient crosses his arms with the nonin- volved hand under the invalved elbow and the nonin- volved forearm supporting the involved forearm, The therapist, sitting facing the patient, supports the patient under the elbows and assists in trunk flexion forward, avoiding any pull on the shoulders. Some pain-free shoulder flexion is accomplished during this forward ‘movement. The patient is concentrating on trunk con- trol, and shoulder movement occurs without conscious awareness. Retum from trunk flexion is performed actively by the patient. Then, while siting. without back support and with the involved arm supported as described above, the patient is pushed backward and ‘encouraged to regain upright posture atively. Forward fexin in iu ction then done nat only t promote regaining balance but also to incorporate more feapular motion with the shoulder exon already achieved. ‘Trunk rotation is then practiced with the patient supporting his involved arm and the therapist gui trunk motion. Trunk rotation ean be combined wi hhead movements in the opposi ion of the trunk rotation, s0 that the tonic neck and tonic lumbar re- flexes can be utilized as one way to begin to elicit the shoulder components of the upper extremity synergies. The arms and trunk move in one direction while the head turns in the opposite direction, Head and trunk ‘movements are combined with increasing ranges of movement of the shoulder, enabling pain-free shoulder and scapular abduction and adduction to be accom- plished during trunk rotation. Retraining Proximal Upper Extremity Control STAGES 1103 ‘The goal of treatment is to promote voluntary control of the synergies and to encourage their use in purposeful activities. In these stages, all movements in synergy patterns but with inereasing voluntary ye ol ofthese pater. from stage 1 (flaccidity) to sage 2 begining synergy) he is cea are elicited at a reflex level, ust man) ' pn reactions, and facilitation procedures as are necessary to elicit a response. The effects of these procedutes combine to produce a stronger ee ‘The patient tries to move (willed movement) as these facilitation techniques are used. : “The flexor synergy is the first to develop. Within that synergy, the strongest component, elbow flexion, js the first motion to be elicited. Once elbow flexion is seen, the therapist turns concentration from elbow flexion to the proximal components of the synergy with the goal of enabling the patient to “capture the syn- ergy,” ice, bring it under voluntary control (stage 3)- Efforts to achieve voluntary control of the flexor syn- ‘ergy begin with scapular elevation. Lateral flexion of the neck toward the involved side can be used to initiate scapular elevation because the upper trapezius does both motions althoogh it may have “Torgtten” how to elevate the scapula. With the pat supported ona tale in shoulder abdution wi flexion, resistance is given simultaneously to the head ‘and shoulder while the patient is asked to “hold” the head and not let it be moved away from the shoulder. ‘When the trapezius is felt to tespond, both the patient's clot and the therapists esitance emphasis shoulder tleeaion when lateral flexion of the neck i repeated Once elevation begins, active cntracton may he pro- moted by an associated reaction. For example, as the patient attempts bilateral scapular elevation, resis- tance is given to the noninvolved scapula: If the in- volved scapula elevates as a tesul of an associated reaction, resistance is then added on the involved. side as the patient is asked to “hold.” Unilateral scapular elevation ofthe involved arm is attempted next and may be achieved as a result of the previous procedures. If the patient is unable to accomplish the motion, the therapist supports the pa- tient’s arm and assists the patient to elevate the scap- ula, Percussion or stroking over the upper trapezius wil fctate muscle contraction, The paint i then told to hold, “Don’t let me push your shoulder down.” Alter repeated holding with some resistance added, the patient does an eccentric contraction—lets the shoulder down slowly. Then a concentric, or shortening, contrac- tion is attempted when the person is told, “Now pull your shoulder up toward your ear.” scapular ‘evokes other flexor components and tends to inhibit the pectoralis major. The patient repeats scapu- Jar elevation and relaxation as the therapist gently abducts the shoulder in increasing increments. because many patients with hemiplegia experience shoulder occur initiation and cont ‘To move the patient > Scanned with CamScannerpain and/or have should 'S maintained, Once shoulder elevation ond the opposite direction are done from the stat and thie begins to develop some components ofthe extens The extensor synergy test follow the Negor synergy and may need to be assisted in is initia Contraction ofthe pectoralis major, spoies eee jor, a strong component extensor synergy, cn be eed by the associated reaction in which the therapist supports the patien’s arms in a poston between honors abduction and adduction, instructs the patent to bring his arms together, and resists the noninvolved arm just proximal tothe elbow. As contraction occurs bilaterally the patient is instructed, “Don't let me pull your arms apart.” Then he attempts to bring his arms together vol- untaily Because of the predominance of excess tone in the clbow flexors and relative weakness of elhow extensors, clbow extension is usually more difficult to obtain but cean be assisted by the following methous. Bilateral “rowing” is the procedure used to initiate elbow exten- sion. In the rowing procedure, movements toward ex- tension combined with pronation are resisted (Fig 24C.1) and movements into flexion combined with supination are guided (Fig, 24C.2). Rowing is done with the therapist and patent seated facing each other, the therapis’s arms are crossed so that she and the patient grasp right hand to right hand and lft hand 0 left hand. First, elbow extension is elicited as an associated reaction by resisting the noninvolved arm sit moves into extension and assisting the involved Rowing to encourage elbow exlensin: resis- tance to elbow extension combined with pronoton. Figure 24¢.1. 24 Remediating Motor Control and Preformance $69 fm ino extension toward the noninvolved knee. On the affected limb is felt to contract, eee oe fered bilaterally * t Haid after positioning” is used to reinforce vel- try flo. When the paten’s arm is postoned in extension synergy with the elhow in neat ill exten. sion, he is asked to “hold” gaint resiance. To facilitate the extensors, quick srtches are applied 10 the involved arm by lighly pushing back toward elbow flexion When the extensor synergy is seen to come under ative contol itis farther developed through tee ofiltera weigh bearing. The patent leans fo ward onto his extended arms supported by alow scl placed infront of him (Fig. 243). The patient uses the noimelved hand to position the involved hand ona sandbag, pillow, ortoel placed onthe stool Vigor stroking ofthe skin over the triceps or taping is done as the plient attempts to bear his weight on bath tutstetched arms (Fg. 246.4). Once he i succesful weigh is shifted so that the noninylved extremity Irempts to support the weigh of the upper tru ‘Again tapping and tactile stimiaton may be ust Unilateral meight bearing abe used fanetionally to ald ebjects while they ae being worked on by the other hand eg, alding apiece of wood while sawing, hammering, or painting ity holding a package steady while opening it, addressing i, o fastening it suppor ing body weight while polishing or washing large su faces sch asa table of oor. To encourage active elbow extension, once the wiceps is activated via rowing and weight beating, unilateral resistance is offered to the patients attempts to move into an extension pattem. Resistance gives resistance is of Rowing to encourage elbow extension: guided Figure 24: Flour 24 on ebow son nd spite, Nae he ‘support given tothe wrists Scanned with CamScanner$20 Section IV Treatment Principles and Practices Figure 24C.3. Weigh bearing on the affected upper ex: trem. Figure 246.4. Focitaog te Wiceps by feml toring the ‘tendon and muscle belly, ° " ° direction his fo and facies a stronger tion. Other meane tht may be used te fc (one labyrinthine refs having the patient wate hi extemiy, which reste head tuning and pls in the asymmetial tonic neck relln; wecking bith the forearm pronated, which is a strung component of the extensor syncrey and ring the tk toad the poninvalvedsidetofaiiatertenson of the sled fim via the tone lunbar rls, ‘As the synergies come unr voluntary contol, they shouldbe used in funtion actives, Te exte nergy can be used 10 stabilize an abject to be 1 side, to push the arm into the worked on by the oth ve arments, to smooth out a sheet on the ei a Sponge ofthe kitchen counter. The flexor synergy can be used functionally to assist in carrying, items (cuch as a coat, handbag, or brifease), feeding oneself, or putting on glasses. Bilateral pushing and palling activities reinforce both synergies. Sanding, ‘eeaving, ironing, and polishing are activities that use the flexor and extensor synergies alternately and re- peatedly. STAGES 4 TO 6 To promote movement deviating from synergy, ‘motions that begin to combine components of synergies in small increments are encouraged as a transition from stage 3 to stage 4. For example, as the patient begins to extend his arm consistently in response to the unilateral resistance given by the therapist, the therapist guides the direction of movement toward shoulder abduction in conjunction with elbow extension. This breaks up the synergistic relationship of shoulder adduction to elbow extension, The therapist requests the patient to push his hand into her hand as she directs the move- ‘ment away from the patien’s midline. When the triceps and pectoralis major are disassociated, the synergies no longer dominate nd In stages 4 and 5 the goal of treatment is to condition the synergies, ie., 10 promote volunt ovenen tht conbnes component othe on sy fies into increasingly varied combinations of move. ments that deviate fom synergy. Propriceeptive and exterocepive stimuli are still used in this phase of training, but tone reflexes and associated reactions, appropriate in the earlier stages when reflex behavior vas desirable, are no longer used. Willed movement With isolated control of muscle groups is the desired ol. The first outof-synergy motion of stage 4 is hand Sehind the body, which combines relate shouler sbduction (lexor synergy) with elbow extension and forearm pronation (extensor synergy). This tion requires that the strongest components of each syne betsubued. To asin geting the hand bebo te body, a swinging. motion of the arm combined with trunk rotation is helpful if balance is god, this ean be done more easily when standing. “As the hand reaches the back ofthe patient, he strokes the dorsum of the hand against the body to complete the sensory ‘awareness ofthe movement. Stoking the dorsum of the hand ow the back is thought to give direction to the attempted voluntary movement. Ithe patient is unable to do the fll motion actively. the therapist passively moves the patient's arm into final position and strokes the dorsum of the patients hand against his sacrum. The patient, while attempting to do the movernent himself is then assisted into and out of the pattern, Scanned with CamScannerwhich gradually becomes voluntary with practice. Practice, using functional tasks as much as possible, continues until the motion can be freely accomplished, Examples of functional tasks, with the patient standing, include putting a belt on, sorting objects by moving certain objects from the table and dropping them into a bucket placed immediately behind the involved foot, swimming using the crawl stroke, and tucking a shirt ino trousers. _ The second out-of-synergy motion is shoulder flexion to a forward-horizontal position with the elbow cntended. Ifthe patient is unable actively to flex the shoulder forward, even with the therapist providing local facilitation and guidance of movement, the arm is brought passively into position: While tapping over the anterior and middle deltoid muscles, the therapist asks the patient to hold the position. If hold after positioning is accomplished, active motion in small increments is then sought starting with lowering ‘of the arm followed by active shoulder flexion. This continues until the full forward flexion motion can be done. Stroking and rubbing of the triceps are used to assist in keeping the elbow straight as the arm is raised. Raising the: arin to forward-horizontal is involved in ‘any vertically mounted game such as soe of checkers (using Velcro tabs to secure the pieces). Sponge painting is repetitive and essentially nonre- sistive and can be mounted vertically on an easel to practice the same motion. ‘The third motion sought in stage is pronation and supination with the elbow flexed to 90°, Supination ‘would not be expected to be a problem unless the pronators retained some spasticity. The problem would be to combine pronation of the extensor synergy vith elbow flexion of the flexor aynergy. Initially, pronation can be resisted with the elbow extended, and gradually the elbow can be brought inte flexion as the resistance to pronation is repeated. An acti to Consider when fesitance to pronation i still ncessary is Bock prining. It can be positioned to resist prona- tion with gradual changes in the amount of elbow flexion, Resistance to supination or pronation depends co the direction in which the major force is exerted When resistance is no longer required and the patient can supinate and pronate with the elbow near the trunk, should involve this motion has been achieved. Pract Activities that require tuming objects or a dial to tit volving sanding of curved edges o with serews can be used. Some games like Skits are nob operated and require rotary motions, as do card games that require turing the cards over. Wall check- ‘ers can be adapted by the use of threaded dowels that rust be tured to remove and replace them for each tmove on the checkerboard. Once the patient is conf- 24 Remediating Motor Control and Performance 471 dent of these stage 4 movements and his performance is fairly consistent, he is ready to enter stage § training, Movement in stage 5 involves active attempts by the patient to move in patterns increasingly away from synergy. Excess effort is avoided, however, s0 that the limbs will not revert back to stereotyped movements The attempts are bolstered by use of quick stretch and tactile stimulation. Each new motion is incorporated imo functional a ‘The first motion sought in stage 5 to side-horizontal, which combines full shoulder abduc- elbow extens When this can be accom- disassociation of components of the synergies has occurred. When the muscles are still under the influence of the synergies, the arm will drift toward horizontal adduction when the elbow is extended or the elbow will flex when the shoulder is abducted. Practice tion plished, wrth functional tasks assists learning. Activities to encourage sie-horizontal movement ean employ place- a high ment of project or game pieces or materials table to the side of the patient. The table raually moved to require more and absluction ani elbow extension. The ps Js on a project to be done in front of him. +s might include weaving, on a floor loom, golf balls, of stage 5 is arm overhead. To achieve ity the seapula must upwardly serratus anterior must be specifically retr this. If the scapula is bound by spastic retractors, passive mobilization may need to be done before seek- ing. an active response. Passive mol scapula is done by grasping, the v rotating it as the arm is pass ‘overhead position, Once mobilized, the serratus is Activated in its alternate duty of seapula protraction by placing the arm in the forward-horizontal p asking, and assisting, the patient to reach forward. It is helpful to rehearse this motion with the patient using the noninvolved extremity. Quick stretches are applied by pushing backward into scapular retraction and the patient is asked to hold. Once activated, a holding contraction of the seratus is sought. These procedures continue, moving the aem in increments toward the arm overhead position. Once the movement has been achieved, practice with functional ectvities reinforces it. Sanding on an inclined plane is an example of an activity requiring. a forward push with an increasing range of movement in scapular protraction and rotation and shoulder Rexion; doing it bilaterally wll allow the stronger, noninvolved aem to help the weaker one ‘Table tennis would sill be useful, so would shoot baskets. Washing or painting # wall would requ repeated reversal of movement up overhead and down. ‘The third motion sought in stage 5 is supination Scanned with CamScanner472. Section IV. Treatment Principles and Practices and pronation (external and intemal rotation) with the elbow extended. The best way to achieve this control is by using both hands in activites of interest to the patient that involve supination and pronation in various arm positions. One activity that can be used is grasping a large ball with the arms outstretched and then rotating it so the affected arm is on top (pronated) and the unaffected arm is on the bottom (Supinated) and vice versa, The patient can then graduate to handling basketball. To improve supination, the elbow is at first kept close to the trunk and gradually extended. Brunnstrom had no special treatment recommendations to assist in developing disassociation of supination and elbow flexion, Patients who recover comparatively rapidly afier a stroke may spontaneously achieve stage 6; however, many hemiplegic patients do not achieve fll recovery ‘Twitchell (1951) stated that patients who reached stages 3 and 4 within 10 days after stroke recovered com. pletely; this has never been verted in the Ierature In Twitchell’s sample, patients who failed to respond to proprioceptive facilitation did not recover willed movement al all, He observed, and it is generally accepted, that the longer the duration of the flaccid stage, the less likely was recovery. Retraining Hand and Wrist Control ‘Training techniques for return of function in the hhand are presented separately because the hand may be ata different stage of recovery than the arm. Ifthe patient is unable to initiate active finger flexion (hand stage 1) or mass grasp (hand stage 2), the traction response in which stretch of the scapular adductors produces reflex finger flexion or an associated reac- tion to resisted grasp by the nonaffected hand may be used in combination with voluntary effort. In hemiplegia, wrist flexion usually accompanies rasp intially so stability ofthe writin extension must be developed. It is easier for the patient to stabilize the wrist in extension when the elbow is extended; therefore, training starts with the elbow extended and the wrist supported by the therapist. The wrist extensor muscles are facilitated, and the therapist diets the patient to do a forceful grasp by commanding, “Squeete.” The grasp promotes normal synergistic con. traction of the wrist extensors. This is repeated until the wrist extensors are felt to respond, allowing the therapist to remove support from the wrist with the command, “Hold.” Tapping on the wrist extensor mus dls aia lig Once wit etn and gasp aie possible with the elbow extended, the process Gf postoning” percussion, and bald is epesed in increasing amounts of elbow flexion. Emphasis in this stage of training is on wrist stability, although wrist flexion and extension and circumduction may then be practiced. ‘To move from hand stage 3 (Rexion) to hand stage 4 (semivoluntary mass extension) spasticity of the finger fexors must be relaxed using a series of manipu- lations. The therapist reflexively releases the patient's rasp by holding the thumb into extension and abduc- tion. Still holding the thumb, the therapist slowly and rhythmically supinates and pronates the forearm. Cutaneous stimulation is given over the dorsum of the wrist and hand while the forearm is supinated. These ‘manipulations continue until a release of flexor tension is seen by some relaxation of the flexed position. If relaxation is incomplete, further manipulations are done. With the forearm still supinated, rapid repeated stretch stimuli are applied to the dorsum of the fingers by rolling them toward the palm with a rapid stroking motion to stretch finger extensors (Fig. 24C.5). When flexor tension is relaxed, the forearm is pronated and the arm elevated above horizontal (Souque's phenome- non}. Sitoking over the dorsum of the fingers and forearm continues as extension is attempted, but effort exerted should be minimal to avoid a buildup of Imitation syokiness, in which the normal side peiforms a motion that is difeut to achieve on the invaled sid, may be obsrved hen the pation tempts ngr extension. Ale the fingers ca be sola tail extended wth he em raised the ems grade lowered. It thee is an increase of flexor teton ve Acted by decreased rang in extension, in neeesay © spelt ahve manlatons tit eso and facilitate extension. Reaching and picking lage, lighwcigh object and rcleaing them, sh oe Figure 24C.5. Foclioting the finger extensors by use of ue, ighsrech delivered by fopping the dorlwrfoce of he fingers sigh into fesion Scanned with CamScanneris required for stucking cones or paper cups, is one example of an activity to practice finger extension, ‘The larger the object, the greater the extension re- quired. The other extensor type activities are those that require the hand to be used lat, such as smoothing ‘out a garment while ironing or a sheet while making the bed. The second motion sought at hand stage 4 is lateral prehension and release. The patient attempts to rmove the thumb away from the index finger to gain release of lateral prehension while the therapist per- ‘cusses or strokes over the abductor pollicis longus tendon to facilitate this motion. Once the patient has some active release, functional use of lateral prehen- sion is then encouraged. Activities include holding « bbook while reading, dealing cards, and using a key. Once the patient is able voluntarily to extend the fingers to release objects, advanced prehensile pattems (hand stage 5) are encouraged through activities. Musi- ‘eal instruments (tambourine, drum, claves, cymbal, toniom, ete.) provide motivating opportunites for gross use of various hand patterns (Cofrancesco, 1985). As the patient progresses, activities are chosen to reinforce particular prehensions at more precise levels. Holding a pencil or paimbrush encourages palmar prehension Spherical grasp is used to pick up or hold round ‘objects such as a mayonnaise jar lid or an orange, and cylindrical grasp is used when holding the handles of tools. ividval finger movements (hand stage 6) may be regained in rare instances. The patient should be tiven a home program of activities to encourage more and more individual finger use and to inerease speed and accuracy of hand movements, but he shauld also be cautioned about expecting 100% recovery. Gait patterns, principles used in preparation for walking, and ambulation training are also described by Brunnstrom. These principles and procedures fall un- der the primary responsibilty ofthe physical therapist EFFECTIVENESS The relative efficacy of Brunnstrom’s Movement ‘Therapy and Bobath's neurodevelopment treatment was studied on seven selected poststroke patients (Wage- naar et al., 1990). Each subject was randomly assigned to one treatment for 5 weeks and then to the other for 5 more weeks; this was repeated using » B-C-BC 24 Remediating Motor Control and Performance 473 design. Functional recovery of activites of daly living (ADL), upper limb function, and walking ability were assessed weekly. The treatment program included oc- ‘cupational therapy, physical therapy, and nursing and all members of the treatment team adhered strictly to the weitten protocol for each treatment that had been developed from primary sources. The only significantly diferent outcome was greater improvement of gait speed by one patient under the Brunnsirom condition ‘compared with the Bobath condition. This could have reflected the specif training of gait speed in the Brunnstrom method. The lack of difference detected in other subjects and for other assessments could have been the result of alternating short periods of each treatment for each subject, i.e, no subject received a full treatment program that followed one method and these methods have opposite views concerning the use of associated reactions. However, the recovery graphs for each patient showed steady recovery, indicating that both methods were probably beneficial. This cannot be stated with finality, however, as no control condition (ice, no treatment given) was used because of ethical reasons. Patients may have improved spontaneously. cepted tee i iene Scanned with CamScanner