MIDTERMS: 1 - Brunnstrum's
Movement Therapy
03/07/22
● Developed by Signe Brunnstrum
1st systematic approach to
treatment of motor difficulties after
CVA
● Main features:
- Reflex response are used
initially to elicit muscle
response
- Proprioceptive and
exteroceptive stimuli assist
in eliciting the synergies
- Use resistance
- Tactile stimulation
- Facilitate attitudinal
reflexes (head and trunk
control)
- Use of associative reaction
- Relearning occurs in the
sequence of anticipated
recovery
- Encourage repetitions
(engram)
- Muscles are
neurophysiologically linked
and cannot act alone or
perform all their functions
- If one muscle in the
synergy is activated, each
muscle in the synergy
pattern will also be
activated
Synergy - a group of muscles acting as a
bound unit in a primitive and
stereotypical manner
● Motor Behavior of Hemiplegic
patients
- There is loss of inhibitory
control normally exerted by
the higher centers
- There is synergistic motor
behavior
● Recover follows an ontogenic
process usually proximal-distal
and cephalocaudal directions
- Associated reactions
- Homolateral limb
synkinesis
- Proximal traction
responses
- Grasp reflex
- Instinctive grasp and
avoiding
- Soques Phenomenon
● Flexion patterns occurs before
extension patterns in UE
● Reflex motions occurs before
controlled, volitional movements
Hemiplegc patient due to CVA of MCA
affectation
● Loss of inhibitory control normally
exerted by higher centers
● FLACCIDITY lead to
SPASTICITY (gross
flexor/extensor synergies)
Basic Premises:
● In normal person, spinal cord and
brain stem reflexes become
modified and components are
rearrange into purposeful
movement as patient
development progresses
● When the CNS reverts to al
earlier development stages, the
reappearance of these reflexes
may be considered normal
● Reflexes can and should be used
to elicit movement
Jackson’s Dissolution/Evolution in
Reverse
Lowest - motor centers; most automatic
movement
Middle - movement are voluntary; less
automatic
Highest - most voluntary movement
“Under certain pathological Stages of Recovery
circumstances the nervous system 1. Flaccid, no joint movement
reverts to cover a level of evolution.” 2. Spasticity begins to appear; basic
● Dissolution of the nervous system limb synergy appears to as
lead to evolution I reverse associated reactions; minimal
- Lesion in the internal voluntary movement
capsule can affect middle 3. Peak of spasticity, basic limb
motor centers wherein the synergy are done voluntarily with
patient utilizes the lower much effort and cognitive control
motor center 4. Spasticity starts to decline; patient
- Severely involved patient is able to perform complex
will utilize the lowest motor movements that deviates from the
control basic limb synergy
- Less severely involved 5. Spasticity continuous to decline;
utilize the middle motor more complex movements
center patterns are performed; basic
NOTE: full motor recovery requires limb synergy loses its dominance
normal functioning of middle motor in the motor behavior
center 6. Spasticity stops individual joint
movements are possible
General Assumptions (Neuroplasticity) coordination near normal
● Because reflexes and whole limb 7. Normal
movement patterns are normal,
stages development and because The Limb Synergies
stroke appears to result in flexor extensor
“development in reverse”, reflexes
and primitive movement patterns UE
should be used to facilitate
recovery of voluntary movement scapula Retracted, Protracted,
post stroke elevated depressed
● Proprioceptive and exteroceptive
stimuli can be used to evoke Flexed, Extended,
desired motion and total changes abducted, adducted *,
● Newly produced, correct motions ER # IR *
must be practiced to be learned
● Practice within the context of elbow Flexed * Extended *
ADL’s enhances the learning
forearm supinated pronated
process
● Recovery of voluntary movement wrist flexed extended
proceeds in sequence from mass,
stereotype flexor or extensor fingers Flexed, Adducted,
movement patterns (synergies) to adducted flexed
movement that combine features
of the two patterns, finally to LE
discrete movement of each joint
at will hip F*AB#ER EX#AD*IR
knee Flexed Extended ● True grasp reflex - apply distally
moving stimulus will lead to
ankle Flexed # Extended * closing of the hand
● Instinctive grasp reaction -
toe Dorsiflexed Plantarflex application of stationary stimulus
, everted ed *, lead to closing of the hand
inverted * REFLEXOGENOUS ZONE of the
hand
Strongest Flexor ● Instinctive avoiding reaction -
synergy synergy forward and upward movement of
common in UE lead to extension of fingers
UE ● Souque’s Phenomenon - moving
UE above lead to extension of
Weakest Extensor fingers
synergy synergy
common in The Hemiplegic Posture
LE
Part Position
● Muscles not part of either synergy Head Lateral flexion
patterns toward the
- Finger extensors affected side
- Latissimus dorsi
- Ankle evertors UE ● Scapula:
- Teres major depressed
- Serratus anterior and
● attitudinal/postural reflexes retracted
- Tonic neck reflex - Magnus ● Shoulder:
de Kleijns reflexes ADDIR
- Tonic labyrinthine reflex ● Elbow:
● Associative reaction flexed
- Homolateral limb ● Forearm:
synkinesis - flexion of the pronated
right UE lead to flexion of ● Wrist:
left UE flexed and
- Raimiste’s phenomenon - ulnar
application of resistance to deviated
the normal side will elicit ● Fingers:
movement of the affected flexed
side (mirroring effect)
Trunk Lateral flexion
Hand reactions toward the
● Proximal traction response - affected side
flexion/extension of one muscle
voluntarily will result to LE ● Pelvis:
flexor/extensor synergy pattern posteriorly
elevated
 and
retracted
● Hip:
EXADDIR
● Knee:
extended
● Ankle:
plantarflex
ed,
inverted,
supinated
● Knee:
flexed
General Principles of Facilitating Motor
Functions
● The use of postural/attitudinal
reflexes
● Stimulating the skin over the
muscles by rubbing with finger
tips
● Muscle facilitated when in
lengthened position
● Quick stretch facilitates
contraction of the muscles
● Synergy patterns may be
augmented by the voluntary
efforts of treatment
● Visual stimulation and auditory
stimulation for muscle stimulation
Treatment Principles
“Recapitulation of normal movement
developmentally from its reflexive base
to voluntary control of individual motions
that can be used functionally.”
● Treatment progresses
developmentally from reflex to
volitional to functional
● When no motion exist, movement
is facilitated using reflexes,
associated reactions,
proprioceptive facilitation, and or
exteroceptive facilitation to
develop muscle tension in
preparation for voluntary
movement
● Patient is encourage to hold the
elicited response, then to control
its lengthening and finally to move
it back to initial position
● Even when only partial movement
is possible, reversal of movement
from flexion to extension is
stressed within each therapy
session
● Withdraw the facilitatory stimulus
once patient shows evidence of
voluntary control in order to avoid
stimulus dependency
● Reflexes in which the response is
stereotypically bound to a certain
stimulus are the most primitive
and should be dropped out first,
while exteroceptive stimulus
(which are least stereotype)
should be eliminated last
● No primitive reflexes, including
associated reactions, should be
used beyond stage 3
● Emphasis is placed on willed
movement to overcome the
linkages between part of
synergies
● Repetition is necessary to
reestablished motor learning
● Proprioceptive and exteroceptive
stimuli assist in eliciting the
synergies
Brunnstrom’s Approach per
Stage/Stages
Stage
Leg Arm Hand
1 Flaccidi Flaccidi No
ty ty, hand
inability function
to
 perform flexion ty grasp
any past 90 declinin present
movem degrees g lateral
ents in movem prehens
sitting, ents ion
2 Spastici Beginni Gross with combin develop
ty ng grasp foot ations ing,
develop develop beginni sliding deviatin small
s, ment of ng. backwa g from amount
minimal spasticit Minimal rd on synergi of finger
voluntar y, limb finger the es are extensi
y synergi flexion floor, now on and
movem es or possibl dorsifle possibl some
ent some of e xion e. Hand thumb
their with behind movem
compon heel on opposit ent
ents floor e possibl
begin to and buttock, e
appear knee arm
as flexed forward
associa on 90 horizont
ted degrees al
reaction position
s ,
pronatio
3 Spastici Spastici Gross n and
ty ty grasp, supinati
peaks, increasi hook on with
flexion ng, grasp elbow
and synergy possibl flexed
extensi patterns e, no 90
on or some release degrees
synergy of their + reflex
present compon extensi 5 Knee Synergi Palmar
s, ents on of flexion es no prehens
hip-kne can be finger with hip longer ion,
e-ankle perform extende domina spheric
dorsifle ed d in nt, al and
xion in voluntar standin more cylindric
sitting ily g, ankle movem al grasp
and DF with ent and
standin hip and combin release
g knee ations possibl
extende deviatin e, +
d g from voluntar
4 Knee Spastici Gross synergi y mass
 es finger
perform extensi
ed with on
greater
ease.
Arm
horizont
al
position
, arm
forward
overhea
d,
pronatio
n and
supinati
on with
elbow
extende
d

6 Hip Spastici All

abducti ty types of
on in absent prehens
sitting except ion,
or when individu
standin perform al finger
g, ing motion
reciproc rapid and full
al movem range
internal ents, of
and isolated voluntar
external joint y
rotation movem extensi
of hip ents on are
combin perform possibl
ed with ed with e
inversio ease
n and
eversio
n of
ankle in
sitting
CHAPTER 3: BRUNNSTROM MOVEMENT THERAPY
Training Procedure for the Trunk and Upper Extremity

BED POSTURE AND BED EXERCISE

Flexor Posture, Lower Limb

Position: The pt exhibit external rotation and abduction of the hip, and
flexion of the knee.
(affected: R leg)

Posture appears to be caused in part by mechanical and in part by

neurological factors: mechanical, because the weight distribution in a flaccid
lower limb causes external rotation of the hip, and because the weight of
the bedclothes on the limb tends to maintain the described position;
neurological, because the joint positions at hip and knee correspond to
those of the flexor synergy. When this synergy makes its appearance, muscular tension in the flexor and abductor
muscles of the hip contributes to the hip posture mentioned; knee flexion appears simultaneously.

Extensor Posture, Lower Limb

At a date when the extensor synergy of the lower limb is fully developed, a
different limb posture may appear. At the time, spasticity in the extensor
muscles often exceeds that of the flexor muscles. The ensuring posture
becomes characterized by extension and adduction of the hip, extension of
the knee, and plantar flexion of the ankle.

Procedure & Positioning: To move in bed, instruct the pt to carry the

involved leg with the uninvolved leg by placing the uninvolved foot under
the involved leg. While this serves, the intended purpose, it may have the
undesirable effect of increasing hip adduction on the involved side so that a crossed-limb posture results. Thus the
patient must be instructed to realign the involved lower extremity to avoid excessive adduction.

Recommended Bed Posture, Lower limb

Position: Pt is in supine position.
Procedure: Ask the pt to slightly flexed the hip and knee. Then the PT will put a small pillow/rolled towel under the
patient knee and let the patient rest her leg on the top of the pillow/towel.

Recommended Bed Posture, Upper limb

Position & Procedure: The upper limb is supported on a pillow in a position that is comfortable for patient. Abduction of
the humerus with respect to the scapula must be avoided as it deprives the shoulder joint of the stabilizing action of the
lower portion of the glenoid fossa on the humeral head and slackens the superior portion if the capsule, thus
predisposing to a downwaed subluxation of the humeral head. In handling the the patient, traction on the affected arm
when moving around in bed.

BED EXERCUSES
PASSIVE AND ACTIVE ASSISTED MOVEMENTS

Turning from supine to side-lying position

Position & Procedure: Pt is in supine position. The affected arm is placed close to the body, and in turning the patient
rolls over the affected arm. If pain is encountered, an alternative method may be employed in which the affected arm is
held at the wrist by the unaffected hand. Assuring that the scapula is abducted and that glenohumeral joint integrity is
maintained, the patient then rolls to the affected side.

In turning towards the unaffected side, it is more difficult because it requires active participation of the affected limb.
Position: supine with pt affected limb bent slightly then the affected arm is held at the wrist by the unaffected hand. Pt
rolls towards the unaffected side.

Prone position for “unlocking” flexed joints

Position & Procedure: Pt is in prone position where the affected side close to the edge of the treatment table, the head
rotated toward the affected side. The flexed elbow is elevated until the upper arm is horizontal, then the shoulder is
inwardly rotated and by means of a sweeping movement the dorsum of the hand is brought to a position of the buttocks
then the arm is brought in an outward and forward direction, which represents the extension stroke.
TRUNK AND NECK TRAINING IN SITTING POSITION
SITTING TRUNK BALANCE

The listing phenomenon

Position & Procedure: The patient is first assisted into symmetrical sitting posture away from the back of the chair. When
the assistance is withdrawn, the patient’s trunk begins to list towards the affected side, as if drawn by a magnet, and if
the listing is not checked, a fall may result.

It is rather peculiar that the listing should occur toward the affected side
because once the center of gravity of the upper portion of the body has
been shifted slightly toward that side, the trunk muscles on the unaffected
side would be the ones required to check the movement.

The statement that trunk listing occurs toward the affected side is not
intended to imply that this is universally so. Occasionally, a slight trunk
deviation toward the unaffected side may be observed. This deviation, however, appears as a rather stationary posture,
not as gradually increasing trunk listing. Possibly, trunk deviation toward the unaffected side may be explained as a
compensatory habit that patient has acquired to avoid listing in the opposite direction. It should also be noted that
listing may be related to perceptual deficits, especially among patients with left-sided hemiplegia, or inaccurate
recognition of verticality.

Evoking Balancing Response

Position &Procedure: Sitting. The patient is hen pushed off balance, first gently, then more vigorously. Note how the
patient supports the affected arm to protect the shoulder joint. This arm posture also prevents the patients from
grasping the side of the chair with the normal hand. The balancing responses at this time are not automatic, but
eventually the patient may be given a light push without warning.

Disturbing the balance in the direction toward which the

patient tends to list is considered particularly import.

Trunk Bending Forward and Obliquely Forward

Position & Procedure: the pt sits in a straight-back chair and supports the affected arm as before. For the trials, and as
long as need, the therapist guides the trunk and arm movements by
holding her hands under the patient’s elbow (Fig. 3-3A). if the patient’s
trunk balance is poor, the therapist may use her own knees to stabilize
the patient’s knee, because the knee on the affected side has a
tendency to fall into abduction.

As the trunk inclines forward, the therapist guides the patient’s arms in
order to attain glenohumeral and scapular motions. Because the
serratus anterior muscle may not be functioning on the affected side
and the antagonistic muscles may be tight, the instructor gently assists
the forward movement of the scapula by passively upwardly rotating its
medical border, traction on the arm should be avoided.
The movement is more demanding in terms of trunk control if it is performed in oblique direction, forward to the left
and forward to the right. When the therapist guides these movements, it is suggested that she assume the standing
position because she can then follow through more thoroughly, and she has the patient’s balance better under control.

Trunk Rotation
Position & Procedure: The pt is in neutral position. The
patient’s arms are close to the body and relatively
relaxed, expect for the upward pressure on the elbow
on the affected side. As the trunk rotates, the patient
maintains a firm grip around the affected elbow, and
the arms swing rhythmically from side to side; the
principal movements are shoulder abduction on one
side and shoulder adduction on the other side. Each
time the movement is reversed the arms are lowered
to the starting position before the trunk rotates
towards the other side.

The patient support the affected RM a before, and

the therapist initially guides the movements. trunk
rotation is first performed gently and within small
range, then the range is gradually increased.
Throughout the movement, the patient looks straight
ahead, which results not only in movement of the
upper body with respect to the pelvis but also in
rotation of the trunk with respect to the head and
neck. A certain amount of neck mobilization is thus
obtained without the patient noticing it. Additional
head rotation takes place if the head rotates
maximally to the left while the trunk rotated toward
the right, and vice versa.

Head and Neck Movements

Position & Procedure: restrictions in the range of the head and neck
movements are common among elderly individuals, and stroke patients
are no exception. Some increased flexibility of the cervical spine may be
obtained from flexion and extension movements and from side-bending
and rotation movements. Manual “spine lengthening” by traction on
the head may be included.

Neuromuscular control of head and neck movements within the

available range is usually present following a stroke, and this control
may be utilized to facilitate shoulder girdle movements over which the
patient may have little or no control. As a example, the upper trapezius
muscle may be observe to contract when resistance is given to head
side-bending, yet the patient may be unable to use the same muscle
when attempting to elevated the shoulder girdle. The physical therapist
holds one hand over the acromioclavicular region, the other hand one
the side of the patient’s head, which is inclined toward the shoulder,
and gives the commands “Hold”, “Don’t let me pull your head away
from the shoulder. If an isometric or lengthening contraction is
successful, it is followed by a shortening contraction
During the procedure, resistance is given on the shoulder as well as on
the head; the patient’s attention is focused on the head movement,
and he experiences the sensation of “holding”. Thereafter, the patients concentrates on holding the shoulder “close to
ear,” and pressure on the shoulder is emphasized. The tension in the shoulder elevators muscles, which has been built
up during resisted head side-bending, may thus make voluntary shoulder elevation materialized. If additional facilitation
is required, associated reaction may be used.

Range of Motion
Position & Procedure: (Left hemiplegia). The physical therapist supports the
patient’s wrist and hand with her left hand, and by cupping his elbow joint
with her right hand, she us able to maintain proper joint position at the
shoulder (Fig. 3-6A). Note also that she maintains his wrist in slight
extension with her index and middle finger (or index finger and thumb)
placed against his thenar and hypothenar eminences, both of which are
flexogenous to flexion. From this basic position, the therapist is able to
guide the patients through full range of motion at all joint, both within and
outside synergy pathways. (Fig 3.6B and C)

In this very early recovery stage, the patient’s attention is drawn to “up”
and “down” or “pull” and “push” movements, even though he may be
unable to assist; forearm supination is usually incorporated in all “up” or
“pull” movements.

If the range of motion is performed too rapidly, spasticity may be

evoked in the dominant components of the synergies. The patient may
sense this tension and be able to assist in achieving the movements. if
excessive spasticity develops, however, the patient’s efforts must be
modulated, and, in fact, very gentle passive movements may be required
to gain more normalized tone. When active motion resumes, the physical
therapist may wish to support the patient’s arm with one hand only so that
the other hand is free to palpate or facilitate as needed to attain the
desired active movements (Fig.3.7). Additionally, full range of motion may
be sacrificed top gain even a modest amount of volitional control.

Maintenance of free, though not excessive, range of motion of the

shoulder joint complex is emphasized, and the physical therapist may have
to guide the patient’s scapula into upward rotation when range of motion
at the shoulder exceeds 90 degrees of flexion, simulating the requirements
of normal glenohumeral rhythm (Fig. 3.8).

If the patient anticipate pain, muscular tension increases, and pain

on passive movement is aggravated. Mobilization of the shoulder joint
without forceful stretching of tense muscle is therefore desirable.

Patients who experience pain if the PT attempts to move the arm with respect to the trunk may have no
complaints during trunk movements that, if properly guided, result in a considerable amount of shoulder mobilization.
First, the patient feels secure because he supports the affected arm himself and is thus able to protect the
shoulder. Second, his attention is focused on trunk movements, and whatever shoulder movements occur are hardly
noticed by the patient. Third, during trunk rotation, both neck and lumbar reflexes play a pan in causing an alternate
increase and decrease in the tension of the pectoralis major muscle on the affected side. When tension in this muscle is
decreased, abduction can proceed in larger range without resistance by the muscle and without pain. When the
shoulder abductor muscles begin to participate actively during trunk rotation, additional release of tension in the
pectoralis major muscle may ke expected, and painless abduction is further enhanced. Once the patient is conbdent that
no pain will be produced, active assisted movements of the one with respect to the mink may begin.
Note: do not touch the flexorgenous of the hand. All planes should be done.
SHOULDER PAIN

Techniques for Painless Shoulder Movements

Position & Procedure: The procedure begins with shoulder flexion,
first performed bilaterally, then unilaterally. The starting position of
the arm for the movements is a seen in Figure 3-9A. 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
made. 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'). See Figure 3.9B
Shoulder elevation performed actively by the patient tends
to evoke activity in all component of the flexor synergy, particularly
if resistance is applied. It also has an inhibitory effect on
components of the extensor synergy, notably on the pectorals major muscle. This inhibition is utilized by
physical therapist to abduct the arm gently small increments each time the patient repeats the movement. The
rhythm of this repetition is regulated by the therapist's voice directing the procedure. "Pull up, let go, mill up, let
go," and so forth. The direction movements is oblique, halfway between forward and sideward the strictly
sideward direction is likely to cause pain and is avoided.
At one time or another during the elevation procedure, the patient, attention is drawn to supination of
the forearm. Note that alternate supination and proration 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 facilitator, (both belong to the flexor synergy), the two movements should be combined.
External rotation of the shoulder, required too abduction beyond the horizontal, has thus been introduced
painlessly, and the stage set for further elevation of the arm. Head rotation toward the normal side is usually
contributes to relaxation of the pectoral major muscle.
After the arm has been carried well above the horizontal
position and if no pain is present, the command "Reach overhead
and straighten out your elbow" may be given. First, however, the
patient must rotate the head 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 parents
who have made sufficient progress.
It is equally effective employ shoulder gridle retraction and
its opposite movement, protraction, as a starting point for
shoulder mobilization (Fig. 3.10 A and B). Like shoulder elevation,
shoulder retraction is comparatively easy for stroke patients to
carry out. Elevation and retraction are both components of the
flexor synergy, and both tend to produce tension in associated
flexor muscles. Bilateral shoulder retraction ("pinching of the
shoulders in the back,") according to the patient may be accentuated by cutaneous stimulation in the
interscapular region. The therapist scratches or pinches the skin in a direction toward the vertebral column,
which indicates to the patient where the movement should take place and possibly facilitates the condition of
the required muscles.
The techniques described result In increased range of motion at the shoulder and serve to organize and
develop the flexor synergy. A small-range movement in the opposite direction—that is, in the path of the
extensor synergy—is performed between the patients flexion efforts so that actually both synergies are being
developed. As training progresses, special emphasis is given to the development of the extensor synergy.
 Eventually the two synergies are combined in a "roundabout” fashion, with the additional movements of
supination-external rotation and pronation-internal rotation incorporated in the guided movement.

SUBLUXATION OF THE SHOULDER JOINT

Activation of supraspinatus muscle
(Left Hemiplegia)
Position & Procedure: Patient is in sitting position.
The therapist hands should be holding the wrist and elbow of
the patient. Since the patient cannot voluntarily externaly
rotate her shoulder the therapist will assist her patient to
externally rotate the shoulder.

Reinforcement of Voluntary Abduction

(affected side: Right)
Position & Procedure: Pt is in sitting position, the shoulder is abd. while
the head is rotated at the normal side.

When position sense and passive motion sense are impaired or absent,
the patient often spontaneously turns the head toward the affected side
because of the need for visual guidance; this guidance may be of greater
benefit to the patient than the facilitator effect of the tonic neck reflex.
(The possible advantage of an obliquely placed mirror to enable the
patients to see the arm while the head is rotated toward the affected side
has been investigated. In general, the mirror image of the arm appeared
to confuse, rather than aid, the patients investigated.)

Use of Proximal Traction Response

Position & Procedure: Pt is in sitting position
During the spastic stage, weak voluntary contractions pf components
of the flexor synergy may be reinforced by a sudden stretch of, or
continuous traction, any one of the flexor muscles. Such stimulation
results in reflex contraction not only of the stretched muscles but also
of other muscles belonging to the flexor synergy. The flexor muscles of
either shoulder, elbow, wrist, or digits may be subjected to this kind of
stimulation, and, when the response spreads to other flexor muscles,
the command “Hold” (for isometric contraction) or “Pull” (for
shortening contraction) is given.
When the patient is seated, retraction of the shoulder girdle and hyperextension of the shoulder are part of the
response so that a shortening of the entire limb, a “shortening synkinesis,” results.

EXTENSION MOVEMENTS

Bilateral Contraction of the Pectoralis Major Muscle

If patient initiate any part the extensor synergy, the pectoralis major muscle on the affected side can usually be
activated by the utilization of a reaction comparable to Raimiste’s phenomenon. Both the supine and the sitting
positions lend themselves well to procedure.

When this reaction a evoked in the sitting position, the therapist stands facing the patient and supports his arms in a
forward-horizontal , position with maximal shoulder internal rotation. Resistance is applied to the medial side of the
normal arm just above the elbow as the patient is asked to adduct that arm horizontally. Firm resistance by the therapist
brings the pectoralis major muscle into strong contraction, and, after some latency, a response is likely to appear also on
the involved side. Voluntary bilateral contraction is now solicited by the command "Don't let me pull your arms apart,"
followed by "Now, bring your arms toward each other again." This
activity may also be performed as a "waist squeeze," as is illustrated in
Figure 3-12.

Although to to the pectorals major muscle usually develop, at an early

dare, elbow extension, a weak component of the extensor synergy,
usually lags behind. During the period of synergy dominance, a
contraction of the triceps muscles is obtained only in conjunction with
that of the pectoralis major muscle, because shoulder and elbow
components of the extensor synergy are firmly linked. Impulses of
various origins may have to be set up if the patient is to succeed in
extending the elbow through complete range. Examples are as
follows:

1. Head rotation toward the affected side. This aids in releasing

tension in the flexor muscles of the elbow and simultaneously
promotes a background tension in the triceps muscles.
2. "Waist squeezing." Since activation of the pectoralis major muscle is
usually accompanied by contraction of the elbow extensors, this
activity may be used to establish background tension M the elbow
extensors. Once this tension is available, the emphasis is directed from
shoulder adduction to extension, and the patient is asked to
straighten the elbow (Fig. 313).
3. Pronation of the forearm by the physical therapist or by the patient
(who then uses the unaffected hand for that purpose) prior to the
patient’s effort to extend the elbow. The supinated position inhibits elbow extension.
4. Trunk rotation toward the normal side. The patient places the pronated forearm against the lateral side of the thigh
on the normal side and pushes in a downward direction.
5. Vigorous back and forth stroking of the skin over the triceps muscles. This is done as the patient makes an effort to
push, that is, to extend the elbow.
6. Bilateral “rowing exercise” against resistance. This activity takes advantage of the facillatory effects of proprioceptive
impulses originating on the normal side and in the trunk. The physical therapist, seated in front of the patient, guides
the movement and offers resistance on the normal side and, as soon as possible, on the affected side as well. Trunk
movements accompany the "rowing,” as they would in a rowboat; series of repetitions are required. When the patients
pushes, the forearms are pronated; when the patient pulls, they may be supinated, if the therapies finds the appropriate
girp.
 7. Unilateral resistance to a push movements in the path of
the extensor synergy. This action may be applied with the
therapies standing behind the patient or sitting in front.
Resistance may be applied to the proximal portion of the
patient’s palm with a grip that also keeps the wrist extended,
or with grip over the patient’s closed fist.
8. "Hold-after positioning" technique. The affected arm is
guided into nearly full range of the extensor synergy until the
elbow is just short of full extension. "Hold, don't let me push
your wit back” is the command. A number of rapid, small-
range, backward pushing movements by the therapist elicits
a series of stretch reflexes in the triceps muscles, which
reinforce the patient's voluntary effort. The patient feels that
he can offer resistance, and this is encouraging to him. A
shortening contraction may then be possible.
9. Weight bearing. The patient leans forward and uses the
normal hand to guide the affected hand to the weight
bearing surface. Once the fist has made contact, the body
weight is shifted onto the affected arm, which now has to
function to support body weight as if it were the forelimb of
a quadruped animal (compare Magnus, the positive
supporting reaction, 1926, and Brain, the quadmpereal
extensor refire, 1927). See Figure 2-15A. The extensor
muscles of the elbow seldom fail to respond to this
challenge. This activity may also be performed with the
affected arm abducted, as in Figure 3-15B
10. Use of the supine position. If at an early date poor results
are obtained with the patient seated, the supine position
may be chosen for traning. Because of labyrinthine influence
(Magnus and de Kleijn, 1912), this position markedly favors
extension. The facilitatory influenceof the supine position on
elbow extension is demonstrated by the patient in Figure 1-
8C It was noted earlier in this chapter that carryover of arm
control from the supine to the sitting position does not
necessarily take place. Thus, if the supine position is used to
introduce background tension in the extensors, such tension
must be “captured" in such a way as to permit its carryover
to the more functional fining position.

Early Training of Serratus Anterior

It is well known that a patient with an isolated paralysis of the serratus anterior muscle resulting from a
peripheral nerve lesion is unable to raise the arm overhead; in fact, such a patient does not succeed in raising the arm
above the horizontal position. In patients with hemiplegia, the flexor synergy, when complete, enables the arm to
abduct 90 degrees, but not beyond this point. One may therefore suspect that the serratus anterior lies idle, particularly
when it can be ascertained by inspection and palpation that the trapezius and the deltoid muscles contract, strongly.
This assumption is further borne out by the observation in this stage patients with hemiplegia often display a marked
winging of the scapula when an attempt is made to raise the arm forward and overhead (Fig. 3-16B). The position of the
scapula seen in this figure bears a striking resemblance to that seen in patients with lesions of the long thoracic nerve.
If in the sitting or standing position a patient is to succeed in raising the affected arm overhead to a vertical or
near-vertical position, painless range of motion at the shoulder must be present; the pectoralis major muscle must allow
 elongation without offering resistance; and serratus anterior
muscle, as well as the glenohumeral muules, must function
satisfactorily.
Techniques employed for achieving painless range of
motion at the shoulder, for relaxing the pectoralis major
muscle, and for evoking responses in the glenohumeral
musdre have already been discussed. The approach suggested
to facilitate the contraction of the serratus anterior will be
dealt with presently. For these methods to be potentially
successful, a certain amount of control of muscles belonging
to the two basic limb synergies is a prerequisite. The
technique cannot be applied with a patient whose upper limb
is essentially flaccid.
Passive mobilization of the scapula, previously
describe, may be repeated here before active participation by
the patient is requested. For such mobilization, the therapist
grasps around the medial border of the scapula to aid its
forward sliding and its upward rotary movement on the rib
cage as the arm is being elevated. The training procedures to
be described are first rehearsed on the unaffected side to
ascertain that the patient fully understands what is expected
and experiences the accompanying sensations.
Stimulation of the serratus anterior muck may begin with the patient's arm supported in a forward-horizontal
position. After requesting that the patient reach forward— a movement that is assisted—the therapist briskly pushes
the arm backward in an attempt to evoke a stretch reflex in the serratus anterior muscle (Fig. 3-16A). Simultaneously,
the therapist gives the command "Don't let me push your arm back." The patient's attempt to comply may result in a
strong contraction of the pectoralis major muscle, but this will not bring the desired result. To avoid the contraction of
the latter muscle, the arm must be brought into a more lateral position and the stimulation repeated.
Next, the patient's arm is raised obliquely upward, eventually to an almost vertical position, as seen in Figure 3-16C.
With the grip shown in the illustration, a number of rapidly repeated downward pushing movements are executed, and
the physical therapist calls out "Don't let me push your arm down,” followed by "Reach for the ceiling." If an active
upward reach does not materialize, the procedure is repeated. In the case of the patient illustrated, the serratus
anterior muscle "caught after several repetitions, and, when this happened, the upward reach was reinforced by
resistance.
As an alternative to the above proredure, the "arm to rear" movement illustrated in Figure3-16D is
recommended. When the sequence begins, the arm is supported, as in Figure 3-6A. The patient is told to move the arm
in front of the body and reach toward the opposite shoulder; this movement is resisted. With each repetition the arm is
raised to a somewhat higher position until the patient's hand is above the head.
The patient's active effort is requested throughout this series of motions, and his task is simply to "pull over," a
movement over which he has good control. As the arm is being passively raised by small increments, the anterior
portion, then also the middle portion, of the deltoid muscle become active. The final movement, when the arm touches
the ear, requires full range in upward rotation of the scapula, and, if the movement is resisted strongly, a spreading of
efferent impulses to the serratus anterior muscle may be anticipated. Alter the serratus anterior muscle has responded
to one or both these manipulations, the patient must learn to maintain the arm elevated without assistance. The arm is
positioned overhead, and, when response, is felt, the command 'Hold- is given, and the therapist assisting so that the
patient must do all the work. Partial success is demonstrated by the man in Figure 3-16E. An emphatic “Don’t let your
arm fall down” or Don’t you dare let your arm fall down” seems further to reinforce the patient’s voluntary effort. The
last command must not be given unless the therapist is reasonably sure that the patient has the ability to comply.
Experience with this technique is required before a prediction can be made concerning the patient’s ability to “obey” the
command.
Withdrawal of Therapist’s Assistance
So far, the physical therapist has utilized certain techniques to aid the patient to perform movements in the path of the
basic limb synergies. The therapist has guided, assisted, and resisted the movement synergies and their individual
component; has introduced reversal of movements direction; and has step outlined and directed the procedures.
Assistance must now gradually be withdrawn so that the paetient becomes independent of the therapist for basic
synergy movements.
In addition, if associated reaction and tonic reflexes have been used to facilitate the development of background
tensiomn, the patients must now be weaned from their influence. This requires increasing amounts of voluntary control,
as illustrade in Figure 3-17.

Practical Use of Basic Limb Synergies

Movement therapy becomes more meaningful if the patient can utilized whatever control has been gained from the
above procedures for function activities. Even though at this time the control of the affected arm is limited, it may be
used in many ways. During the synergy stages, the affected arm serves as an aid to the normal arm, which must be
relied on for all major activities, skilled and unskilled. Advantage may be taken of the patient’s control of flexor as well as
extensor components, and of the entire synergies when these are under control.

The extensor synergy may be used as follows:

1. To stabilize an object on the table while the unaffected hand is used to open an envelope or write a letter. Such
stabilization is also useful for many household activities.

2. To stabilize an object between the affected arm and the body. A jar may be held steady while the unaffected
hand unscrew its top; a handbag or a newspaper may be heal under arm while the unaffected hand opens a
door; and so forth.
 3. To push the affected arm through a sleeve while the normal hand holds the garment in such a position that the
movement may follow the path of the extensor synergy. (First, however, the forearm must be pronated, for if it
remains supinated or semisupinated, elbow extension is inhibited)

The flexor synergy or its components may be utilized for many activities
1. To carry a coat over the forearm, elbow flexed, provided the elbow flexor muscles are sufficiently strong.

2. To carry a briefcase or handbag after the handles have been placed in the hand. The grip of the affected hand,
however, can seldom be relied on for any length of time because the grip may loosen if the patient’s attention
does not remain focused on hand closure.

3. To hold a small object in the hand, such as a toothbrush, while the normal hand squeezes dental cream on the
brush.
1. FLEXOR ACTIVITIES
A. Hand to chin
B. Hand to ear (affected side first then unaffected)
C. Hand to opposite elbow
D. Hand to opposite shoulder
E. Hand to forehead
F. Hand on top of head
G. Hand to back part of head

H. Stroking movements
-start on forehead, stroking over the top of head to the back part of the head

-stroking with both hands on lap, affected hand performs a stroking movement over dorsum of
forearm on N side and follows the arm up toward shoulder and neck

2. EXTENSOR ACTIVITES
Gin correct ni sir ang resistance
Patient must go towards extension so dapat straight ang kamot pwede siya pa downward, upward,
front kag back. Adjust mo lang ang resistance kung diin pakadto. Picture 3 may sample nga resistance.
PT ma push upward, px downward

3. ARM TO REAR OF BODY

A. Starting in flexor synergy

Starting pos: Shoulder elevated, shoulder slightly abducted and hyperextended, elbow flexed, hand
touching lateral part of hip. Then bring to rear.

B. Starting with extensor synergy

Px will perform successive pushing forward, obliquely sideward, downward, and backward directions
C. Starting with trunk rotation, standing erect
kung kaya mag tindog sang px, stand erecct, feet few inches apart, arms hanging ar side
Rotate trunk let arms flop around. If guidance needed sang px refer pic 3

4. ARM RAISING FORWARD TO HORIZONTAL POSITION

Si px gaubra, ma quide lang si PT

“px please try to raise your arm with elbows straight”
“kung nd mag tadlong tap the deltoid, and triceps, then hold after positioning. Kung ma tadlong na ni
px you will do a little upward, downward movement until naga dako ang range”-sir

5. PRONATION AND SUPINATION OF FOREARMS, ELBOW FLEXED

Px is seated, elbows flexed, both arms supported by pillow placed on lap. Then elbows raised off the
lap, px is instrcted to keep elbows in contact c the truckwhile turning palms up and down

6. ARM RAISING TO SIDE HORIZONTAL POSITION

Px sitting position c arms at the side

“please raise your arms sidewards, down…(repeat)”
“paguso kamo kung palms up/down. Kung ano lang makaya ni px”-sir
7. TURNING PALMS UP AND DOWN, ELBOW EXTENDED

Px may be in sitting or standing position

Actively naubra ni px
Ask px to raise arm sideward with palms facing the ceiling. Then turn palms up and down

HAND TRAINING
1. INFLUENCE OF IMITATION SYNKINESIS

Px in sitting position ask px to close open both hands at the same time
“assist ang affected side sa pag open kag close”-sir

2. GRASP ELICITED BY PROXIMAL TRACTION RESPONSE

“instruct px to bent the elbow, so I resist mo ang elbow flexion then you can see that the patient is
closing its fingers. Or you can also have resisted forearm supination or wrist flexion. Instruct px to bent
the wrist against your resistance then the patient will bend” -sir

3. WRIST FIXATION FOR GRASP

A. Synergy influence on wrist muscles

Flexor synergy voluntary performed or evokedas an associated reaction

Extensor synergy is usually accompanied by fixation of wrist in extension

B. Wrist positioning

When wrist drop is present, PT supports px wrist in extension whenever arm is moved passively. If
during in an active extension movement, resistance is applied to the proximal portion of palm to
maintain the wrist extended. Avoid reflexogenous zone mag uyat!

Px will try to close fist with resistance “squeeze” positioning of the wrist on extension is important!!!

C. Activation of wrist extensor muscles

Wrist, arm, elbow are extended. Refer to 3rd pic

1st pic: tap ang wrist… “squeeze”
2nd pic hold… relax

D. Wrist stabilization for grasp, elbow flexed

Arm raised forward, elbows slightly flexed, wrist extended then ask px to hold position
Then slowly bring the arm towards the chin, hold.
“ang goal diri ma bring ang hand to the mouth nga wala ga kuom ang kamot kag wala naga flex ang
wrist”-sir

E. Hyperactive wrist extensor muscles

Elbow passively flexed by therapist

Start in flexed position, instruct px to “squeeze” then “stop squeeze”
Then do it again in extension, same command.
“nd pag deretchohon extend ang elbow, kay ara sa extensor synergy pattern ang px mabudlayan ka
mag close open sang kamot”-sir

4. RELEASE OF GRASP AND ELICITATION OF EXTENSOR REFLEXES

A. First stage of manipulation

Sit infront of the px.

First hold thumb of px out of her palm by gripping the thenar eminence. Then supinate the forearm of
the patient. Pronate and supinate sa forearm, emphasize supination.

Self-manipulation of px
Let px grasp the thumb on the affected side. Instruct px to rotate forearm with palms facing up/ceiling

B. Second stage Manipulation

Supinate px hand, R hand abduct px thumb, L hand will “swatt” px fingers (daw gina close open ang
fingers/daw ga claw form)

C. Third stage of manipulation

Stay beside affected side of px. Raise arm into horizontal position, grasp thumb with L hand, use heel
of R hand to stroke over MCP jt distally

Reinforcement of reflex, fingers passively flexed by stroking over the dorsum of hand and digits.
Fingers bounce back to extended position

Although not part of the series of manipulation. Px are encouraged to reduce tension independently
in the finger flexors by using thumb release.
D. Tonic thumb reflex

Px is in sitting position. The response of the thumb becomes intensified if the forearm is supinated
maximally when arm is elevated. The hand should reach at least the height of the forehead or higher.

5. ALTERNATE FIST CLOSURE AND FIST OPENING

First give support to the wrist and forearm of the px, then slowly lower the hemiplegic arm while the
elbow is flexed but before that request px to make a fist but command is “squeeze” and “stop
squeeze”.

Starting position

Elbow flexed, squeeze and stop squeeze

Gradually lower same squeeze and stop

Last nagid nga lower

6. TRANSITION TO VOLUNTARY FINGER EXTENSION

A. Semivoluntary mass extension of digits

Staring position
Start by holding elbow with both hands and allowing px to extend fingers
Another position

B. Individual thumb movements

Px sitting, arms in forward horizontal position, elbow extended
“px please move away your thumb from other fingers with minimal effort”

Lateral prehension
Same position but with wrist flexed. “px move two thumbs around each other”
The normal side may push the affected thumb around “px please assist your affected side to extend
your thumb”

7. PREHENSION TYPES
A. Advanced prehension
-Palmar prehension
Different sizes of small objects. Using the affected hand pinch/grasp objects one by one

-Cylindrical grasp
Different diameters of cylindrical objects “using affected hand grasp each object one by one”
-Spherical grasp
Different sizes of ball. (same command)

B. Hook grasp
Px may have to use normal hand to place handles in affected hand, then make a conscious effort to
maintain hand grip.
Start sa unaffected side

C. Lateral prehension
Px is in sitting position. PT sits in front of px

Starting position ang thumb away sa palm

Place resistance sa index finger tas observe kung ga extend ang thumb
Chapter 5: Brunnstrom's Movement Therapy
02/29/22

TRUNK BALANCE
a. MAGBANUA
Trunk Listing in Sitting
● Position: sitting with her back resting on the back of the chair
● Assume left hemiplegia; instruct the px to try not to rest his/her back on the chair
● Px tends to list towards the affected side

● Success in maintaining standing balance cannot be expected unless the px can

balance the trunk in sitting position without any support on the side or the back
Beevor’s Observations
● Pxs with hemiplegia tend to list toward the affected side
● He investigated using resisted and unresisted side motions of the trunk on both
sides of the midline
● He concluded that px with, for example, left-sided involvement who displayed the
listing phenomenon had difficulty in controlling the trunk whenever the motion
took place to the left
● On the other hand, motions to the right were well under control
b. DINEROS
Deficiency of Perception
● Position: px sitting and therapist sitting facing the px
● The forward movement is guided with support under the px’s elbow
● Instruct the px to lean forward and backward repeatedly
 ● If the affected side lags, the therapist will guide the movement by supporting the
px’s elbow by one hand while assisting forward flexion of the trunk of the
affected side to promote symmetrical movement

● For trunk flexion with rotation promotes weight bearing through the hip toward
the trunk is implied as well as balancing responses
● Instruct the px to rotate the trunk to the right side then lean forward, backward,
forward, and backward again. Then repeat to the left side

● 10 reps
MODIFICATION OF MOTOR RESPONSES OF THE LOWER LIMB
1. BILATERAL CONTRACTION OF HIP FLEXOR MUSCLES
a. Macahilo
● Position: sitting and extending the trunk to the back of the chair
● There’s a brief bilateral activation of the hip flexor mm
● For greater ROM, the px makes a quarter turn on to the normal side then will try
to return the movement; or can sit on a stool without support
● The hip flexor mm will respond with a lengthening contraction of the trunk and
shortening contraction during the return of movement
 ● Also, hip flexor mm may activate when the px attempts to maintain erect sitting
against resistance or move into trunk flexion with or without resistance
● Instruct px to slightly move the trunk forward so that he/she can sit straight in the
chair without resistance. Then PT will apply resistance during the attempt of the
px. There is a response in the affected leg

2. UNILATERAL CONTRACTION OF HIP FLEXOR MUSCLES

a. Maguad
● Position: px sitting and therapist sitting beside px near the affected leg
● Passively flex the px’s hip flexor mm and let the px do it by him/herself or actively
● PT will elevate the px’s foot to have her hip in unilateral flexion then instruct the
px to not let the foot touch the floor (hold)

3. ACTIVATING THE DORSIFLEXOR MUSCLES OF THE ANKLE

a. LORANA
● Position: px in flexor synergy pattern of lower limb
● Apply resistance to the hip flexion component
● Px demonstrates dorsiflexion on the ankle
 ● Try to perform on stroke pxs. Apply resisted hip or knee flexion, you will see
dorsiflexion of the toes/toe. That is what you call, “Marie-Foix Reflex”
REQUIREMENTS FOR THE EARLY STANCE PHASE
1. REFLEX RESPONSE
a. MALIMBAG
● Also known as Bechterev’s reflex or Marie-Foix reflex
● Assume the affected side is right and the unaffected side is left
● Position: supine, knee slightly flexed
● Instruct the px to flex hip on unaffected side. If the px has no control in hp flexion,
passive extension of the toes is administered or grip around the px’s toes
● (+) if the foot in the affected side dorsiflexed

● If the px’s foot is dorsiflexed, grip the toes and have it plantarflexed (hold on the
tip of the toes and try to curl it up), so that the hip and knee will flex upward
2. INTRODUCING VOLUNTARY EFFORT
a. JAGORIN
● n/a
3. REINFORCEMENT OF VOLUNTARY EFFORT
a. MERIVELES
● The next step in training the dorsiflexor mm is to have the px perform dorsiflexion
without the use of reflex elicitation
● Position: sitting or supine
● Supine: have the px lie on his/her back with hips and knee bend. PT place left
hand on top of the affected side w/c is the R thigh et place the right hand on the
dorsum of the foot
● Instruct the px to point the toes upward and don’t let the PT put the foot down
● Then ask the px to perform the shortening contraction by saying, “please point
your toes up again”
● Sitting: ask the px to dorsiflex his/her ankle by instructing to pull his/her foot
upward and leg into extension
● Again, lift the toes upward and then lift the leg to extension
● Repeat this procedure until px can perform dorsiflexion c hips and knee extended
 ● Can increase difficulty by having the px perform this activity in a high chair and
then progress gradually into a standing position. Then px is able to perform
dorsiflexion in standing position with hip and knees extended. The synergy
pattern is diminished and the non synergy pattern is introduced

● It is difficult to dorsiflex the ankle if the knee is extended. It could be easy for the
px to do it if hips and knees are flexed. You can try to perform it with a stroke px

4. DORSIFLEXION WITH EVERSION

a. HIPOLITO
● Position: supine c hips et knee extended
● PT place resisting hand on lateral aspect across the dorsum of the foot to cause
the long toe extensor mm to dorsiflex the foot. Then the px will try to hold the
everted position on the hand on inversion motion
● Instruct the px to hold the foot steady and don’t let the foot turn in

● Just do that after positioning. Just position your ankle in dorsiflexion and eversion
motion. Then instruct the px to hold the position while you try to push toward
inversion

5. ABDUCTION
a. ONGANON
● Raimiste’s Phenomenon to evoke a reflex contraction in the abd mm of the hip et
to facilitate et strengthen the contraction of these mm
● Assume px has trendelenburg gait
● Position: supine
● Instruct the px to move the unaffected limb out without raising it off the bed
● PT will oppose the movement by resisting the lat side of the limb
● If the resistance is strong, the unaffected limb will be held in place and the
affected limb is seen to move into abd

6. HIP ABDUCTION IN SIDE LYING

a. HALLADOR
● Assume affected side is on the R
● Position: side-lying on L side. PT will stand behind the px
● The unaffected hip and knee should be flexed partially
● PT will do a vigorous percussion on px’s gluteal mm to wake up those lazy mm
● Inform the px to do a tapping motion on his/her butt mm
● Next, lift the affected side c hip et knee flexed partially
● Ask the px to hold the position, don;t let the leg fall down
● If px is unable to comply c the command, the procedure is repeated
● This method means building up a reflex tension in abd mm
 ● Hindi sa buli, sa side sang hip (gluteus medius, not gluteus maximus)

7. BILATERAL ACTION OF HIP ABDUCTOR MUSCLES IN STANDING

a. PARCON
● Assume R is affected
● Position: standing; PT standing next to the px on the R side for assistance
● Supposedly there’s a handle or parallel bar behind the px
● Instruct px to stand on one leg on L leg and raise R leg sidewards
● Repeat to the opposite side
● On the R side, what we should be observing is if there’s a pelvic dropping on the
opposite side. If this happens, PT will assist the px on holding the L pelvis and pull
it upward. On the R side, PT will press it downwards.
● Repeat the instructions.
● Another technique that can be used is w/o the parallel bars. Same px et PT
position.
● PT will hold the px’s opposite arm for assistance and other arm, and repeat
instructions

8. UNILATERAL ACTION OF HIP ABDUCTOR MUSCLES IN STANDING

a. GUMBAN
● The last et most demanding activity in sequence of procedures designed to
activate et strengthen the hip abd mm on the affected side.
● Position: standing. PT standing beside px to assist et instruct
● Assume px has R hemiplegia
● To perform, we need a supporting surface w/c is the table
● Instruct the px to put hands on the table. With hands on the table, it can support
the px in performing the activity
● Instruct the px to lift the leg out to the R side then hold for 5 sec and lower it
down
● When lifting the leg, make sure that the trunk is upright et avoid leaning over.
Keep the pelvis level et do not let it turn or rotate to the side
 ● Repeat the instructions

KNEE FLEXORS AND EXTENSORS

1. SUPINE POSITION
a. QUIDATO
● Position: supine
● PT will hold the px's foot down so that the sole slides on the horizontal surface
● Instruct the px to pull the knee up toward the chest
● The sensation thus evoked is emphasized by asking the px, “do you feel the sole
of the foot sliding on the surface?”
● Repeat the same movement and tell the px to feel it again
● After a few trials, instruct the px to slide the foot back to his/herself
● Alternate knee flexion and extension movements in small range are then
attempted without permitting the sole of the foot to leave the surface

● When you practice knee bending/flexion, always have the px heel slide on the
surface. Don’t try to practice knee flexion nga ang sole sa foot wala na ga slide sa
bed kay that can be a false knee flexion exercise

2. SIDE LYING POSITION

a. GUMAYAN
● Used if extensor tone in the supine position is prohibitive of voluntary knee
flexion
 ● Position: side-lying c knee flexed
● Side-lying position may be advantageous for 2 reasons: (1) the gravitational
influence on the lower extremity has been reduced , creating a lighter load for
the px to life; and (2) knee flexion may be facilitated by the influence of the
asymmetrical tonic labyrinthine reflex, which favors flexion of the uppermost
limbs in the side-lying position

● Just perform knee bending/flexion in a side-lying position. Hindi lang nga

side-lying tapos nka knee bend/flex na nga daan
3. SITTING POSITION
a. RESABA
● If the knee flexor mm cannot be induced to contract in the supine or side-lying
position, activation of these mm practically always succeeds in the sitting position
● Position: sitting et places his/her foot forward on the floor, the heel touching et
the knee short of full extension
● Instruct the px to slide the foot backward, touching the floor c the heel et then c
the ball of the foot, as the foot slides underneath the chair et the knee flexes to
an acute angle
● This movement is first performed several times on the unaffected side, then
attempted on the affected side
● At the onset, the PT may have to assist the backward sliding movement of the
foot directly, or aid by lifting the lower portion of the px’s thigh just enough to
reduce friction of the px’s foot on the floor
● The lifting is accomplished by a grip just above the knee; this grip also permits
palpation et manipulation of the tendons of the knee flexor mm
 ● You can use a skateboard to eliminate the friction of the sole of the foot or you
can just use fabric (madanlog) to lessen friction

4. SEMI STANDING, HALF PRONE AND STANDING POSITION

a. GABASA
Semi-Standing Position
● PT will tell the px to sit on a table while the feet is on the ground to increase the
amount of hip extension et enables further development of reciprocal knee
flexion et extension

● In that position, the px is sitting on a high chair on the edge. Instruct the px to
bend the knee. Hindi lang pag patindog tindogon imo px. This is a knee flexion
exercise

Half-Prone Position
● Position: leaning over the table to partially support the trunk
● This is used as an intermediate step between sitting et standing o reinforce
alternate knee flexion et extension c increasing amounts of hip extension,
● Instruct the px to lean over the table c your arms resting on top
● In extension, the elbow of the px is extended
● Instruct the px to extend the arm
 ● That is the proper way of doing the one leg stand, you’re going to bend the knee.
Not the hip.
Standing
● Position: standing facing the table and px will try to flex the affected knee w/c is
the R side
● The half-prone position is gradually modified to a standing position when the px
can flex the affected knee while the hip on the affected side is kept extended
● It is a sign that the hemiplegic limb synergies no longer influence the px’s
movements

5. PAWING
a. SINDOL
● The term “pawing” has been coined for this exercise because it resembles the
movements of a horse’s pawing as the animal scrapes the ground with his
forefoot
● Position: standing
● When the px flexes the knee, his ankle will plantarflex so the toes scrape the
ground as the px attempts to lift the leg up and then when extending the knee,
the ankle will dorsiflex

KNEE STABILITY IN STANDING

1. STANDING KNEE BENDS
a. DUMAGO
● For the px’s safety, the PT or assistant stands behind the px, supporting the trunk
on both sides of the chest
● The px is guided in shifting weight toward the affected side c both (scenario:
affected is R side) c both knees slightly flexed
● After that, the px will flex another 10-20 degrees, the extended, but not
hyperextended
● A satisfactory response of the knee extensor mm will probably be evoked on the
affected side

● When the px becomes more confident, support may be withdrawn and resume
when the px fails to distribute weight equally on two legs
● When standing knee bends are first attempted, many pxs will automatically
incline the trunk forward and bend the head and neck forward, perhaps to
incorporate visual cues
● Additionally, if the px experiences knee buckling on the affected side, the PT may
place his/her leg in front of the px’s knee to minimize knee flexion

● Also, to control hyperextension by placing his/her leg behind the px’s knee and
gently encouraging weight bearing on a slightly flexed knee
 2. LATERAL WEIGHT SHIFT AND MARKING TIME
a. SOBREMISANA
● Assuming that the px has a left side hemiplegia
● Position: standing
● Instruct the px to slightly bend the knees and put all weight to the R leg then lift L
leg and put L leg down then put all weight to L leg then raise R leg and repeat

● Marking time pa, difference of lateral weight shift and marking time
PREPARATION IN WALKING
a. DONATO
● The purpose of this activity is to obtain a rapid release of tension in the quads
mm et sufficient knee flexion to allow the affected limb to swing through freely in
walking
● Position: standing; Px uses hand support to minimize balancing difficulties
● PT will assist the px starting c the unaffected side of the limb then the affected
side
● Instruct the px to perform heel strike, scrape the toe backward and knee up;
repeat; this is repeated 4-6x
● Same c the opposite/affected side
 ● If the extensor synergies are dominant, instruct the px to perform heel strike, sole
of the foot pass through the side of the other leg, repeat

TRUNK ROTATION WITH ARM SWING

a. TORRATO
● There are 2 steps: (1) standing; and (2) walking
● (1) standing et PT behind px to support
● Px will move the arm wrap around the body as trunk rotation to the left et right
● Instruct the px to move the left arm to the right, next to the left. Repeat
● (2) slow walking c exaggerated trunk rotation
● Arm wrapped around the body is not attempted. It is understood that when the
left foot steps forward the trunk rotates toward the left and right arm swings
forward
● Instruct the px to start walking
● To avoid confusion, do not mention to the px to walk right and left. Just simply
tell the px to start walking

ASSISTED WALKING
a. DIONIO
● Also known as Skater’s Waltz position that means that the walking activities will
be performed outside the parallel bars
● Assume the px has R side hemiplegia
 ● PT position him/herself on the affected side and hold both px’s hands
● Instruct the px to transfer weight towards PT’s body and take a step using L leg

OBSTACLE CLEARANCE
a. UBAY
● For reasons of safety and to remove the px’s fear of falling, the PT walks next to
the px, supporting him/her
● The walking rhythm is maintained at the end of the obstacle course as both PT
and px continue to step over imaginary obstacles that are described as becoming
lower and lower until they are less than an inch high
● Clearing obstacles in walking is also recommended for pxs c other gait deviations,
et all pxs should be given the opportunity to walk on and off carpets
● Start stepping on the unaffected leg c PT assisting the px and c obstacles
● Next obstacles that lower down

WALKING INSTRUCTIONS AND STAIRS

a. DIAZ
Walking Instructions
● Hold the px’s L hand using PT’s R hand and px’s R hand on PT’s L hand
● PT slightly flexes his/her R knee and instructs the px to follow flexing L knee
towards PT’s R knee et shift px’s weight towards PT’s body. This position is called
Skater’s Waltz c knees slightly flexed
 ● Instruct px to take short steps first c unaffected side

Stairs
● When stair walking is first attempted, the px’s unaffected foot must be in
ascending et the affected foot in descending
● If handrail is available only to the unaffected side, px must have to descend
backwards
● Assume L side hemiplegia
● Instruct the px when ascending, he/she must first step with the unaffected side

● When the px tries to descend, affected foot first

● Do not let the px walk on the stairs nga wala kamo sa iya side